Intraoperative prediction of non-sentinel lymph node metastases in breast cancer using cytokeratin 19 mRNA copy number: A retrospective analysis.

One-step nucleic acid amplification (OSNA) is a molecular procedure used intraoperatively for the detection of sentinel lymph node (SLN) metastases. The aim of the present study was to define a cut-off of cytokeratin (CK)19 mRNA copy number predictive of positive completion axillary lymph node dissection (ALND). The OSNA procedure was employed for SLN analysis in 812 patients with T1-T2 N0 breast cancer. A total of 197 patients with SLN metastases were retrospectively analyzed. A total of 40 patients (20%) had non-SLN metastases. Receiver operating characteristics curve analysis established a cut-off of 5,000 CK19 mRNA copy number with 75% sensitivity and 72% specificity. The positive and negative predictive values were 40.5 and 92%, respectively. Multivariate analysis showed that this cut-off and tumor localization in the outer or lower-outer quadrant of the breast were significantly associated with non-SNL involvement (P<0.001 and P=0.025, respectively). The findings of the present study support the conventional cut-off of 5,000 copies for intraoperative decision to perform ALND, whereas ALND can safely be avoided in patients with tumor located outside the outer or lower-outer quadrant of the breast if the CK19 mRNA copy number is <5,000.

Quality of life, anxiety, and postoperative complications of patients undergoing breast cancer surgery as ambulatory surgery compared to non-ambulatory surgery: A prospective non-randomized study.

PURPOSE: According to the latest recommendations a minimally invasive approach should be used to manage breast cancer and a global policy for minimizing costs encourages shorter periods of hospitalization. The aim of this study was to investigate the impact of length of hospitalization on quality of life, anxiety and depression and postoperative complications. METHODS: This is a prospective observational study of 412 female patients with breast cancer requiring a first mastectomy or lumpectomy to assess the impact of the length of hospitalization on quality of life (using the European Organization for Research and Treatment of Cancer Quality of Life QLQ30 and BR23 questionnaires) at postoperative day 14 (D+14), levels of anxiety at d-1 and D+1 (according to the Hospital Anxiety and Depression scale) and postoperative state at D+21. RESULTS: Our study included 244 patients that had ambulatory surgery and 124 that had non-ambulatory surgery. Global health status was significantly better for ambulatory surgery patients (adjusted p-value=0.014). There were no significant differences between the two groups for levels of anxiety, pain, lymphoceles and postoperative complications. No cases of nausea and vomiting requiring medical treatment were reported for either group. CONCLUSIONS: Breast cancer surgery can be performed using ambulatory surgery with no significant differences compared to non-ambulatory surgery in terms of quality of life, perioperative anxiety, and postoperative complications. Indeed, our study suggests that ambulatory surgery improves patient outcome. It should be determined whether the mode of hospitalization has any long-term impact on the patient, as a shorter hospitalization period would allow decreasing waiting times.

Evaluation of Pre-Therapeutic Assessment in Endometrial Cancer Staging.

OBJECTIVE: The aim of this retrospective cohort study is to evaluate the concordance between the preoperative MRI and histology data with the final histopathological examination. METHOD: This is a retrospective observational study of 183 patients operated for endometrioid cancer between January 2009 and December 2019 in the surgical oncology department of the Lorraine Cancer Institute (ICL) in Vandœuvre-lès-Nancy. The patients included are all women operated on for endometrioid-type endometrial cancer over this period. The exclusion criteria are patients for whom the pre-therapy check-up does not include pelvic MRI and those who have not had first-line surgery. The final anatomopathological results were compared with preoperative imaging data and with endometrial biopsy data. RESULTS: For the myometrial infiltration, the sensitivity of MRI was of 37% and the specificity of 54%. To detect nodal metastases, the sensitivity of MRI was of 21% and the specificity of 93%. We observed an under estimation of the FIGO classification (p = 0.001) with the MRI in 42.7% of cases (n = 76) and an overestimation in 24.2% of cases (n = 43). There was a concordance in 33.1% of cases (n = 59). We had a poor agreement between the MRI and final histopathological examination with an adjusted kappa (κ) of 0.12 [95% IC (0.02; 0.24)]. There was a moderate concordance on the grade between the pretherapeutic biopsy and the final histopathological examination on excised tissue with an adjusted kappa of 0.52 [95% IC 0.42-0.62)]. Endometrial biopsy underestimated the tumor grade in 28.9% of cases (n = 50) (p < 0.001), overestimated the tumor grade in 6.9% of cases (n = 12) and we observed a concordance in 64.2% of cases (n = 111). CONCLUSION: The pre-operative assessment of endometrial cancer is inconsistent with the results obtained on final histopathological examination. A study with a systematic review should be done to assess the performance of MRI, only in expert centers, in order to consider a a specific care management for endometrial cancer patients: patients who have had an MRI in an outpatient center should have their imaging systematically reviewed, with the possibility of a new examination in case of incomplete sequences, by expert radiologists, and discussed in multidisciplinary concertation meeting in expert centers, before any therapeutic decision. The sentinel node biopsy must be used for low and intermediate risk endometrial cancer.

Pre-operative axillary ultrasound with fine-needle aspiration cytology performance and predictive factors of false negatives in axillary lymph node involvement in early breast cancer.

PURPOSE: Breast cancer is the most common cancer among females worldwide. Axillary lymph node involvement is an important prognostic factor in pre-operative evaluation. The aim of this study was to evaluate the sensitivity and accuracy of AUS during the initial breast cancer diagnosis and the contribution of ultrasound with guided FNAC (AUS + FNAC) in cases of suspicious node. METHODS: A retrospective study was conducted at the Lorraine Cancer Institute between 1 January and 31 December 2015. It included patients with early breast cancer, all of whom received AUS. If axillary node involvement was suspected, FNAC was performed. Sentinel lymph node biopsy (SLNB) and/or axillary lymph node dissection (ALND) were performed depending on FNAC results. RESULTS: In total, 292 patients were included. 88 patients (30.1%) had a suspicious lymph node on ultrasound and had FNAC, of whom 53 tested positive for axillary node involvement (60.2%). Among the 35 patients who tested negative with FNAC, 15 had axillary metastatic involvement. Performance of AUS + FNAC was better than that of AUS alone, with sensitivity, specificity, positive predictive and negative predictive values of approximately 44.5%, 100%, 100% and 72.4%, respectively, and accuracy of approximately 77.4%. Luminal A subgroup, axillary involvement of less than two positive nodes or nodal tumor of less than 7 mm are independent factors of false negative rate. CONCLUSIONS: AUS performance would seem to be improved by FNAC, with a false negative rate of approximately 26%. It may be possible to reduce the false negative rate of AUS if its contributing factors are taken into consideration, along with the impact of specific echographic signs as revealed by experienced radiologists.

Predictive factors of axillary positive sentinel lymph node biopsy in extended ductal carcinoma in situ treated by simple mastectomy at once.

BACKGROUND: The incidence of positive sentinel lymph node biopsy (SLNB) in ductal carcinoma in situ (DCIS) ranged from 0 to 14%. The main hypothesis would be the presence of an invasive contingent on the final histology. The objective was to identify predictive factors of sentinel lymph node positivity in the management of extended ductal carcinoma in situ treated by simple mastectomy. METHODS: This was a retrospective study carried out at the Lorraine Cancer Institute from January 2003 to December 2017. Women with DCIS on core-needle biopsy whose management consisted of simple mastectomy and SLNB procedure were included. RESULTS: 188 patients were analyzed. Preoperatively, 18 patients (9.6%) had DCIS with microinvasion, while the others had pure DCIS. Eight patients (4.2%) had positive sentinel lymph node biopsy, the majority of which were single micrometastases. Predictive factor of node invasion was microinvasion on biopsy (p<0.01). Only in cases of pure DCIS, the percentage of positive SLNB was reduced to 2.9%. Invasive carcinoma was found in the majority of patients with positive axillary SLNB procedure (75%, n=6), compared to 16.7% (n=30) without SLNB involvement (p<0.01). CONCLUSIONS: The low rate of positive sentinel node biopsy in pure ductal carcinoma in situ suggests that in the absence of microinvasion, the sentinel procedure would seem less appropriate. New techniques for identifying sentinel lymph node biopsy could report axillary staging after definitive histologic results.

[Factors limiting outpatient management in breast surgery]. / Facteurs limitant la prise en charge ambulatoire en chirurgie mammaire.

INTRODUCTION: Breast cancer surgery associates interventions of short duration and low morbidity, mostly accessible for outpatient management. METHODS: We performed a descriptive, retrospective, monocentric study involving 1735 patients operated between 1st of July 2015 and the 31st of December 2017 of a mammary or axillary lymph node procedure. A comparative study was carried out, involving 2 groups of patients treated either on an outpatient or conventional hospitalization mode, in order to find the main medico-social factors that could constitute barriers to this ambulatory modality. RESULTS: In total, 992 patients were treated in outpatient surgery and 743 in conventional surgery. The mean age of the ambulatory group was 56.9 years (±11.2), versus 65.9 years (±13.5) in the conventional hospitalization group. Thirteen stays (1.3%) had to be converted into conventional hospitalization. The main factors limiting outpatient management are age≥70 years, BMI≥25, isolation of the patient, total mastectomy, and drainage. CONCLUSION: Because of social, medical or psychological constraints, the rate of outpatient breast surgery remains in our practice, stable in recent years at 56%. Some ways of improvement can be envisaged, but it is likely that this rate will only increase in a very gradual manner in the years to come.

Preoperative Breast Magnetic Resonance Imaging in Women With Local Ductal Carcinoma in Situ to Optimize Surgical Outcomes: Results From the Randomized Phase III Trial IRCIS.

PURPOSE: We evaluated the addition of breast magnetic resonance imaging (MRI) to standard radiologic evaluation on the re-intervention rate in women with ductal carcinoma in situ (DCIS) undergoing breast-conserving surgery. PATIENTS AND METHODS: Women with biopsy-proven DCIS corresponding to a unifocal microcalcification cluster or a mass less than 30 mm were randomly assigned to undergo MRI or standard evaluation. The primary end point was the re-intervention rate for positive or close margins (< 2 mm) in the 6 months after randomization ( ClinicalTrials.gov identifier: NCT01112254). RESULTS: A total of 360 patients from 10 hospitals in France were included in the study. Of the 352 analyzable patients, 178 were randomly assigned to the MRI arm, and 174 were assigned to the control arm. In the intent-to-treat analysis, 82 of 345 patients with the assessable end point were reoperated for positive or close margins within 6 months, resulting in a re-intervention rate of 20% (35 of 173) in the MRI arm and 27% (47 of 172) in the control arm. The absolute difference of 7% (95% CI, -2% to 16%) corresponded to a relative reduction of 26% (stratified odds ratio, 0.68; 95% CI, 0.41 to 1.1; P = .13). When considering only the per-protocol population with an assessable end point, the difference was 9% (stratified odds ratio, 0.59; 95% CI, 0.35 to 1.0; P = .05). Total mastectomy rates were 18% (31 of 176) in the MRI arm and 17% (30 of 173) in the control arm (stratified P = .93). For 100 lesions seen on MRI, nonmass-like enhancement was more predominant (82%) than mass enhancement (20%). Nevertheless, no specific morphologic and kinetic parameters for DCIS were identified. CONCLUSION: The study did not show sufficient surgical improvement with the use of preoperative MRI to be clinically relevant in DCIS staging. However, this could be reconsidered with the improvement of new MRI sequences and new modalities in magnetic resonance techniques.

Limited effectiveness of patent blue dye in addition to isotope scanning for identification of sentinel lymph nodes: Cross-sectional real-life study in 1024 breast cancer patients.

BACKGROUND: Although morbidity is reduced when sentinel lymph node (SLN) biopsy is performed with dual isotopic and blue dye identification, the effectiveness of adding blue dye to radioisotope remains debated because side effects including anaphylactic reactions. PATIENTS AND METHODS: Using data from a prospectively maintained database, 1884 lymph node-negative breast cancer patients who underwent partial mastectomy with SLN mapping by a dual-tracer using patent blue dye (PBD) and radioisotope were retrospectively studied between January 2000 and July 2013. Patients with tumors <3 cm and with >1 node detected by one of the two techniques (N = 1024) were included in this real-life cross-sectional study. RESULTS: Among the 1024 patients, 274 had positive SLN detected by isotopic and/or PBD staining. Only 4 patients having no detectable radioactivity in the axilla had SLN identified only by PBD staining (blue-only) while 26 patients had SLN only identified by isotopic detection (hot-only) illustrating failure rates of 9.5% (26/274) and 1.5% (4/274), respectively. Among these four patients, two had negative lymphoscintigraphy. Therefore, the contribution of PBD to metastatic nodes identification was relevant for only 2/274 patients (0.8%). Three patients (0.3%) had an allergic reaction with PBD, and anaphylactic shock occurred in two cases (0.2%). CONCLUSIONS: The added-value of PBD to reduce the false-negative rate of SLN mapping is only limited to the rare cases in which no radioactivity is detectable in the axilla (<1%). When a radioisotope mapping agent is available, the use of PBD should be avoided, because it can induce anaphylaxis.

Treatment of vulvar intraepithelial neoplasia with CO(2) laser vaporization and excision surgery.

OBJECTIVE: To evaluate the recurrence rate after a single treatment of vulvar intraepithelial neoplasia (VIN) with CO(2) laser vaporization. MATERIALS AND METHODS: Fifty women with usual-type or differentiated VIN (grades 2 and 3) treated with CO(2) laser vaporization or surgery excision (cold knife or CO(2) laser) were retrospectively evaluated. RESULTS: Of the 50 patients, 41 (82.0%) had usual-type VIN and 9 (18.0%) had differentiated VIN. Moreover, 24 (48.0%) were treated with surgery excision and 26 (52.0%) underwent CO(2) laser vaporization. Laser-treated patients were significantly younger (p < .01) with more multifocal (p < .05) and multicentric lesions (p < .01) than in the surgery group. Recurrence-free survival (RFS) rates at 1 year were 91.0% for the surgery and 65.2% for the laser vaporization groups (p < .01). At 5 years, RFS rates were unchanged for the surgery group and dropped to 51.3% (p < .01) for the laser group. On the univariate analysis, current smoker (p = .03), multicentric VIN (p = .02), and laser vaporization treatment (p < .01) had a statistically significant impact on RFS. One patient progressed to invasive cancer (2%). CONCLUSIONS: The recurrence rate after CO(2) laser vaporization requires regular, close, and extended monitoring.

Responsiveness of EORTC QLQ-C30, QLQ-CR38 and FACT-C quality of life questionnaires in patients with colorectal cancer.

BACKGROUND: The aim of this study was to compare the responsiveness of the European Organization for Research and Treatment (EORTC) quality of life questionnaires (QLQ-C30, QLQ-CR38) and the Functional Assessment of Cancer Therapy-colorectal version 4 questionnaire (FACT-C). METHOD: This prospective study included 127 patients with colorectal cancer: 71 undergoing chemotherapy and 56 radiation therapy. Responsiveness statistics included the Standardized Response Mean (SRM) and the Effect Size (ES). The patient's overall assessment of his/her change in state of health status was the reference criterion to evaluate the responsiveness of the QoL questionnaires. RESULTS: 34 patients perceived their health as stable and 17 as improved between the first and the fourth courses of chemotherapy. 21 patients perceived their health as stable and 22 as improved between before and the last week of radiotherapy.The responsiveness of the 3 questionnaires differed according to treatments. The EORTC QLQ-C30 questionnaire was more responsive in patients receiving chemotherapy, particulary functional scales (SRM > 0.55). The QLQ-CR38 and the FACT-C questionnaires provided little clinically relevant information during chemotherapy or radiotherapy. CONCLUSION: The EORTC QLQ-C30 questionnaire appears to be more responsive in patients receiving chemotherapy.

[The surgery after. . . retroperitoneal lymph node dissection and surgery of the residual masses after chemotherapy for advanced testicular cancer]. / La chirurgie d'après Le curage rétropéritonéal et la chirurgie des masses résiduelles après la chimiothérapie dans les cancers avancés du testicule.

Thirty-six cases of retroperitoneal lymph node dissections for residual mass after chemotherapy for testicular cancer are reported. In a reference center, the recruitment is modified by the severity of the situations related to very big masses, tumors of poor prognosis and resistant tumors. Lymph node dissection is often atypical and surgery of metastatic residual masses is frequent (13 operations). The 8-year global survival remains stable, over 90%. The 5-year cumulated risk of recurrence is 20%, but these situations can be overtaken.

[Laparoscopic surgery and robot]. / Coelioscopie et télérobotique.

Twenty years ago, laparoscopic surgery entirely changed the traditional style of surgical operations. However, it was difficult to perform some interventions, particularly in restricted space or if acts of reconstruction are necessary. It was necessary to develop new technologies such robotic surgery. We detail the different technologies and we precise the place of the robotic surgery in oncological surgery. In conclusion, we believe that, in the near future as robotic technology continues to develop, it could replace traditional surgery not only in the treatment of benign diseases but also in malignant illnesses.

Prevention of biliary lesions that may occur during radiofrequency ablation of the liver: study on the pig.

OBJECTIVE: To prevent bile duct injury by using a cold 5% glucose isotonic solution cooling in the bile ducts when radiofrequency (RF) is performed in a porcine model. SUMMARY BACKGROUND DATA: Complications that may arise during liver RF ablation include biliary stenosis and abscesses. METHODS: The RITA 1500 generator was used for the experiments. Two lesions were performed in the left liver. The pigs were killed 1 or 3 weeks after the procedure. An ex vivo cholangiogram was obtained by direct injection into the main bile duct. Samples of RF lesions, of liver parenchyma near and at a distance from the RF lesions, underwent pathologic studies. Two groups of 20 pigs each were treated: one without perfusion of the bile ducts and the other with perfusion of cold 5% glucose isotonic solution into the bile ducts. The Pringle maneuver was used in 50% of the RF procedures. Radiologic lesions were classified as biliary stenosis, complete interruption of the bile duct, or extravasation of the radiologic contrast liquid. RESULTS: Histologic lesions of the bile ducts were observed near the ablated RF lesion site and at a distance from the RF lesions when a Pringle maneuver was performed. Radiologic and histologic lesions of the bile ducts were significantly reduced (P < 0.0001) when the bile ducts were cooled. CONCLUSIONS: Cooling of the bile ducts with a cold 5% glucose isotonic solution significantly protects the intrahepatic bile ducts from damages caused by the heat generated by RF when performed close to the bile ducts.

Results of preoperative lymphoscintigraphy for breast cancer are predictive of identification of axillary sentinel lymph nodes.

The aim of this study was to identify the variables associated with successful peroperative sentinel lymph node (SLN) localization. We studied 201 patients with T1, T2, N0 invasive breast cancer who underwent a SLN procedure from 1999 to 2003. Of these 201 patients, 55 underwent peritumoral and 146 underwent periareolar radioisotope injection before the blue dye injection. All patients were operated on by breast conservative surgery and axillary dissection after SLN biopsy. Age, weight, menopausal status, previous biopsy, localization of the tumor, results of lymphoscintigraphy, site of radiotracer injection, tumor size, tumor grade, experience of surgeons, and the number of invaded axillary nodes were analyzed to determine whether they had any significant correlation with successful identification of SLN. Variables found to have a statistically significant influence on the SLN identification rate and on preoperative lymphoscintigraphy identification were introduced into a univariate and multivariate logistic regression model. In multivariate analysis, successful lymphoscintigraphy (P < 0.0001) and the absence of metastatic axillary nodes (P < 0.005) were associated with successful identification of SLNs. The peritumoral injection of radiotracer (P < 0.001), patient age > 60 years (P < 0.003), and localization of the tumor in the upper outer quadrant (P < 0.004) were associated with failure of lymphoscintigraphic visualization of SLN. The technique of SLN detection thus appears to be better for patients with low risk of invaded axillary lymph nodes.

[Use of sentinel lymph node technique in cutaneous melanoma: preliminary experience]. / Utilisation de la technique du ganglion sentinelle dans la prise en charge du mélanome malin cutané: expérience préliminaire.

The aim of this study was to determine the contribution of the technique of sentinel lymph node (SLN) biopsy by preoperative lymphoscintigraphy and patent blue injection in management of primary cutaneous melanoma (MM). Sixty three patients with stade I primary MM were operated between March 1999 and January 2003. Preoperative lymphoscintigraphy was performed the day before surgery and peroperative patent blue injection was used to identify SLN. All hot and/or blue lymph nodes were removed and examinated in standard histology and immunohistochemistry. The population was 31 men and 32 women. The MM were distributed between upper extremities (9), lower extremities (24), trunk (19) and head and neck (11). A SLN was identified in 98%. Aberrant drainages were found in 13%. The average number of SLNs removed was 3.6 [0-15]. Fourteen patients (22%) had SLN positive for malignant disease, with micrometastasis in nine cases. The sentinel node was false-negative in 12.5% with a medial follow-up of 14 months. In conclusion, preoperative lymphatic mapping combined used of peroperative detection by a hand-held gamma probe and patent blue injection is a feasible technique to specify the first drainage of MM.

Quality of life among disease-free survivors of rectal cancer.

PURPOSE: To identify factors affecting the quality of life (QoL) of disease-free survivors of rectal cancer. PATIENTS AND METHODS: One hundred twenty-one patients in complete remission more than 2 years after diagnosis were asked to complete three QoL questionnaires: the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30; its colorectal module, QLQ-CR38; and the Duke generic instrument. RESULTS: Patients reported less pain (P =.002) than did controls drawn from the general population. EORTC QLQ-C30 physical scores were also higher among rectal cancer survivors than in the general Norwegian or German population (P =.0005 and P =.002, respectively). Unexpectedly, stoma patients reported better social functioning than did nonstoma patients (P =.005), with less anxiety (P =.008) and higher self-esteem (P =.0002). In the present authors' experience, the QLQ-CR38 does not discriminate between these groups. Residual abdominal or pelvic pain and constipation had the most negative influence on QoL. CONCLUSION: QoL is high among rectal cancer survivors, including stoma patients. Simultaneous use of several QoL questionnaires appears to have value in follow-up and in monitoring the effects of therapy. The impact of residual pain and constipation on long-term QoL should be considered when establishing a treatment regimen.