Risk Factors Associated With Complications After Unilateral Immediate Breast Reconstruction: A French Prospective Multicenter Study.

BACKGROUND/AIM: For women who have undergone a mastectomy, breast reconstruction provides psychological as well as aesthetic benefits. Thus, many patients ask for an immediate breast reconstruction (IBR). The present study focuses on risk factors assiociated with complications after IBR. PATIENTS AND METHODS: A national prospective study (2007-2009) was conducted on 404 patients who underwent an unilateral IBR: 205 implants alone (IA) including 46 tissue expanders, 91 latissimus dorsi musculocutaneous flaps with implant (LDI), 78 autologous latissimus dorsi musculocutaneous flaps (LD), and 30 autologous transverse rectus abdominis musculocutaneous flaps (TRAM). Outcomes concerned major and minor complications, as well as early and late complications. RESULTS: Related risks of complications were different according to the IBR technique. Major complications rate remained moderate and concerned 15% of patients. Obesity and diabetes significantly increased the incidence of major complications. CONCLUSION: To reduce complication rate, the risk factors associated with each type of IBR should be taken into account.

Comparison of the histopathological results of the radioguided percutaneous microbiopsies and the operative specimens of soft tissue tumors of limbs, trunk and retroperitoneum.

INTRODUCTION: Suspicious lesions of sarcoma require preoperative biopsies. If surgical biopsies remain the gold standard, radioguided percutaneous microbiopsies are gaining an increasing importance. The purpose of this study was to compare histopathological results of percutaneous biopsies of soft tissues, trunk and retroperitoneal tumors with the histopathological results of operative specimens. METHODS: This is a retrospective study including 84 patients treated in our institution. The concordance between the results of the microbiopsy and the operative specimen for the benign-malignant differentiation and the histological type was evaluated. The microbiopsy accuracy was calculated. The sensitivity and the specificity of the microbiopsies compared to the operative specimen were also evaluated for the benign-malignant differentiation. RESULTS: The concordance was 0.92 [0.79-1] for the benign-malignant differentiation, 0.97 [0.92-1] for the histological type. The accuracy of microbiopsies was therefore 96% (sensibility=97.0%; specificity=94.1%) for the benign-malignant detection and 97.8% for the histological type. CONCLUSION: Percutaneous microbiopsies play an important part in the diagnosis of soft tissue tumors of the limbs, trunk and retroperitoneum, in particular as a replacement to more invasive surgical biopsies. This study evidences the increasing importance of the collaboration between radiologist, surgeon and pathologist in the diagnosis of sarcoma.

Advanced Techniques in Musculoskeletal Oncology: Perfusion, Diffusion, and Spectroscopy.

The imaging characterization of musculoskeletal tumors can be challenging, and a significant number of lesions remain indeterminate when conventional imaging protocols are used. In recent years, clinical availability of functional imaging methods has increased. Functional imaging has the potential to improve tumor detection, characterization, and follow-up. The most frequently used functional methods are perfusion imaging, diffusion-weighted imaging (DWI), and MR proton spectroscopy (MRS). Each of these techniques has specific protocol requirements and diagnostic pitfalls that need to be acknowledged to avoid misdiagnoses. Additionally, the application of functional methods in the MSK system has various technical issues that need to be addressed to ensure data quality and comparability. In this article, the application of contrast-enhanced perfusion imaging, DWI, and MRS for the evaluation of bone and soft tissue tumors is discussed, with emphasis on acquisition protocols, technical difficulties, and current clinical indications.

Rates of Neoadjuvant Chemotherapy and Oncoplastic Surgery for Breast Cancer Surgery: A French National Survey.

BACKGROUND: The current retrospective study was intended to obtain up-to-date and comprehensive data on surgical practice for breast cancer throughout France, including neoadjuvant chemotherapy (NAC) and the more recent surgical techniques of oncoplastic surgery (OPS). METHODS: In June 2011, e-mail surveys were sent to 33 nationally renowned breast cancer surgeons from French public or private hospitals. The questionnaire focused on all the new cases of breast cancer treated in 2010. It included questions regarding surgical practices, with special emphases on NAC and OPS and other surgical characteristics. RESULTS: The overall response rate for the survey was 72.7 %. The total number of breast cancer cases from the survey was 13,762, which constitutes 26.2 % of the total incidence in 2010. Breast-conserving surgery (BCS) was performed for 71.0 % of the patients, and the results were similar throughout the types of practices. Of these patients, 13.9 % received OPS, either upfront or after NAC. Mastectomy was performed for 29.0 % of the patients, which is consistent with French official numbers. Among all patients, 16.3 % underwent surgery after NAC. CONCLUSION: To the authors' knowledge, there are no publications of national figures on NAC or OPS rates to date. They are convinced that this study offers real-life surgical care information on a large population and covers France's breast cancer surgical landscape. Mastectomy rates in France remain stable and consistent with those in other European countries. However, additional large-scale retrospective studies are required to confirm these figures and further explore NAC and OPS rates as well as surgical practice characteristics.

Focus on Merkel cell carcinoma: diagnosis and staging.

Merkel cell carcinoma is a rare lymphophilic skin tumor of neuroendocrine origin with the potential for rapid progression. Small, localized lesions are diagnosed and treated clinically, but advanced tumors often undergo imaging evaluation. Due to its rarity, radiologists are unaware of evocative imaging features and usually do not consider Merkel cell carcinoma in the differential diagnosis of soft tissue tumors. Appropriate staging is important to determine appropriate treatment and has an impact on patient prognosis. Multimodality imaging is usually needed, and there is no consensus on the optimal imaging strategy. The purpose of this article is to review various aspects of Merkel cell carcinoma imaging and look in detail at how optimal multimodality staging should be carried out.

Screening for vulnerability in older cancer patients: the ONCODAGE Prospective Multicenter Cohort Study.

BACKGROUND: Geriatric Assessment is an appropriate method for identifying older cancer patients at risk of life-threatening events during therapy. Yet, it is underused in practice, mainly because it is time- and resource-consuming. This study aims to identify the best screening tool to identify older cancer patients requiring geriatric assessment by comparing the performance of two short assessment tools the G8 and the Vulnerable Elders Survey (VES-13). PATIENTS AND METHODS: The diagnostic accuracy of the G8 and the (VES-13) were evaluated in a prospective cohort study of 1674 cancer patients accrued before treatment in 23 health care facilities. 1435 were eligible and evaluable. Outcome measures were multidimensional geriatric assessment (MGA), sensitivity (primary), specificity, negative and positive predictive values and likelihood ratios of the G8 and VES-13, and predictive factors of 1-year survival rate. RESULTS: Patient median age was 78.2 years (70-98) with a majority of females (69.8%), various types of cancer including 53.9% breast, and 75.8% Performance Status 0-1. Impaired MGA, G8, and VES-13 were 80.2%, 68.4%, and 60.2%, respectively. Mean time to complete G8 or VES-13 was about five minutes. Reproducibility of the two questionnaires was good. G8 appeared more sensitive (76.5% versus 68.7%, P =  0.0046) whereas VES-13 was more specific (74.3% versus 64.4%, P<0.0001). Abnormal G8 score (HR = 2.72), advanced stage (HR = 3.30), male sex (HR = 2.69) and poor Performance Status (HR = 3.28) were independent prognostic factors of 1-year survival. CONCLUSION: With good sensitivity and independent prognostic value on 1-year survival, the G8 questionnaire is currently one of the best screening tools available to identify older cancer patients requiring geriatric assessment, and we believe it should be implemented broadly in daily practice. Continuous research efforts should be pursued to refine the selection process of older cancer patients before potentially life-threatening therapy.

[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.

[Metaplastic carcinomas of the breast: a morphological and immunohistochemical study]. / Les carcinomes métaplasiques du sein : une étude morphologique et immunohistochimique.

INTRODUCTION: Metaplastic carcinomas of the breast are rare and form a heterogenic group of tumors, characterized by the presence of squamous or sarcomatoid differentiation. PATIENT AND METHODS: In 23 cases, we study the main histoprognostic features, hormonal status, and the expression of HER2, CK5/6, CK14, p63, EGFR, beta-catenin, MUC1 and E-cadherin, the expression of this seven last antigens being also studied in nodal metastases. RESULTS: The different metaplastic types are spindle cell carcinoma (35%), squamous cell carcinoma (26%), osteo- or chondrosarcomatoid (11%) or mixed type (26%). Vascular emboli are seen in 30% of the tumors and perinervous infiltration in 4%. 33% of the patients have nodal metastases. The immunohistochemical features are: RO+: 4%; RP+: 8%; HER2+: 0%; p63+: 74%; CK14+: 83%; CK5/6+: 74%; EGFR+: 100%; E-cadherin+: 70%; beta-catenin: aberrant staining (cytoplasm or weak membrane staining greater than 5%): 74%, negative: 13%; MUC1: aberrant staining (cytoplasm or complete membrane staining greater than 5%): 35%, pure partial membrane staining: 22%, negative: 43%. In 43% of tumors, more aberrant staining for MUCI is present in nodal metastases compared with primitive tumor. CONCLUSION: Metaplastic carcinomas are aggressive tumors, generally with a "triple-negative" and basal phenotype. The expressions of MUC1 and beta-catenin are often absent or aberrant, which could favor metastatic dissemination.

[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.

[Is carotid resection a valuable option in advanced head and neck squamous cell carcinomas]. / La résection carotidienne constitue-t-elle une option thérapeutique dans les carcinomes épidermoïdes évolués cervico-faciaux?

Head and neck squamous cell carcinomas may involve the carotid artery. Surgical treatment of these tumors is a difficult challenge, because of related morbidity and mortality. The aim of this study of international literature was to define the best preoperative and intraoperative strategy which permits carotid resection with acceptable neurologic risk. Pre-operative evaluation of cerebral tolerance to carotid occlusion is performed. If the patient has successfully completed the 30-minute temporary occlusion of the internal carotid artery, a permanent balloon occlusion is performed. Surgical treatment includes carotid resection with or without revascularization using an autogenous graft. Elective carotid resection without reconstruction results in cerebral complications in 0 to 25% of patients, and death in 0 to 30% of patients. If a reconstruction using a graft is performed, cerebral complications occur in 0 to 22% of patients, and death in 0 to 33% of patients. Anastomotic rupture occurs in 0 to 33% of patients. However, many authors reported no neurologic complications and no deaths after performing successful preoperative permanent balloon occlusion of the internal carotid associated with carotid resection. Carotid resection can be performed with an acceptable cerebral risk in selected patients. Preoperative carotid occlusion seems to result in decreased postoperative mortality and morbidity rates. Prospective studies should be done to clarify the benefit of this procedure.

[How to improve the initial management of adult patients with tumors of bone and soft tissues: the experience of a multidisciplinary committee from the Oncolor network before the distribution of regional guidelines]. / Comment améliorer la prise en charge initiale des patients adultes atteints de tumeurs des os et parties molles: expérience d'un comité de concertation pluridisciplinaire du réseau Oncolor, avant la diffusion des référentiels régionaux.

Tumors of bone and soft tissues in adults are rare accounting in France for 2000 to 2500 new cases per year. These tumors are heterogenous and their diagnosis is made after first surgery. Therefore, an early pluridisciplinary approach, by physicians who have acquired an expertise in this field, is advised before any biopsy or surgical resection and at all the further step in the subfrequent management. This paper describes the experience of a pluridisciplinary committee, specialized in malignant tumors of bone and soft tissues in adults, with a highly specialized team which is part of a network in the treatment of cancer in Lorraine, the Oncolor network, before the distribution of regional guidelines. After a description of the organisation of this committee, we made a retrospective analysis of all the cases submitted to these experts advice for the first time, between January and December 2000. This study reveals an insufficient pluridisciplinary coordination at the initial management, which has been done by making regional referentials available, and therefore some errors which lead in some cases to inadapted treatment. It underlines therefore the necessity to implement more actively the present data of science, and to develop the management in multidisciplinary committees. Oncolor aims to harmonize this pluridisciplinary approach as well as to diffuse standard recommendations.