[Axillary lymphadenectomy with muscular padding, without drainage]. / Le curage de l'aisselle avec capitonnage musculaire sans drainage.

OBJECTIVE: Axillary padding without drainage appeared to be a valuable alternative technique to vacuum drainage. The technique employs local muscles or the axillary aponeurosis for padding. We report here the clinical evaluation of muscular padding without drainage. The analysis of these results prompted us to also do a literature search for other alternatives aimed at reducing morbidity due to vacuum drainage. PATIENTS AND METHODS: Muscular padding was prospectively performed by 8 different surgeons on a total of 152 patients at the Centre Rene-Huguenin (Saint-Cloud, France). Follow-up has attained 3.5 years. A comparative assessment of pain was conducted in 30 patients operated on with vacuum drainage. RESULTS: This technique is easy to learn and reproducible. It facilitates post-operative follow-up, always allowing discharge at the 2nd or 3rd post-operative day without any home nursing. The late sequels are not increased. In contrast, pain was twice more intense during the first post-operative weeks compared with vacuum drainage, and the seroma rate was also increased. DISCUSSION AND CONCLUSION: Despite good efficacy, this worsening of pain is a major obstacle to the routine use of muscular padding. A technical improvement has been published very recently where the axillary aponeurosis was used to pad the axilla. It seems to be equally efficient but less painful than muscular padding. This technique is under clinical evaluation and could appear as a valuable option to vacuum drainage. Other alternatives are discussed. Most studies lack a direct comparison with vacuum drainage and a satisfactory evaluation of quality of life is also omitted. New studies with quality of life scales are ongoing. They should allow us to choose options that take this aspect into account in the future.

[Radiotherpay and immediate breast reconstruction with myocutaneous flap in breast cancer of reserved prognosis]. / Radiothérapie et reconstruction mammaire immédiate par lambeau myocutané dans les cancers du sein de pronostic réservé.

In France, immediate breast reconstruction (IBR) for infiltrating carcinoma remains controversial. Many teams advocate the possible event of a post mastectomy radiotherapy and its negative effect on IBR. In our Institute we do not exclude infiltrating breast cancer patient from IBR. In the poor prognostic patients who wish IBR, we recommend autologous IBR to obtain the best aesthetic result with minimum revision procedures and best tolerance to adjuvant radiotherapy. From January 1993 to December 1997, we performed 687 IBR with myocutaneous flap for infiltrating carcinomas. In this group only 68 patients needed postoperative chest wall radiotherapy (45 Gy): 27 TRAM flap, 41 latissimus flap. Only one of the TRAM but 39 of latissimus flaps were associated with a prosthesis. The mean follow-up was 24 months. Fourteen patients developed metastatic disease, and ten were dead at the time of the chart revue. The autogenous TRAM flap tolerate radiation quite well and remain soft and mobile. The latissimus flap associated with a prosthesis developed capsular contracture (BAKER II or III) in 71% of cases. In all cases the cosmetic impairment was not important and the result after capsulectomy remained soft. We concluded that IBR could be offered to motivated patients in all stages of the disease regardless of the subsequent chest wall radiotherapy, and we recommend its use for possible autologous reconstruction.

[Rectus abdominis myocutaneous flaps]. / Le transplant libre myocutané de grand droit de l'abdomen.

The free transverse rectus abdominis myocutaneous (TRAM) flap is vascularized by the inferior epigastric pedicle. There are many techniques according to the indication. We describe the technique for breast reconstruction after mastectomy for cancer. The rectus muscle is taken between the umbilicus and the arcuate line. The skin paddle, was taken transversely like an abdominoplasty. The incision extends from 1 cm above the umbilicus to include the perforators around it. The mean length of the vascular epigastric pedicle is 6 cm. This study was performed from one hundred dissections.

[Breast reconstruction using free rectus abdominis myocutaneous flap]. / Reconstruction du sein pour cancer par transplant libre myocutané de grand droit de l'abdomen.

More than 50% of patients who have breast cancer do not need a mastectomy. Since 1976, reconstruction of the breast is suitable. From 1976 to 1995, we have performed 220 breast reconstructions with a pediculed latissimus dorsi and 510 reconstructions with a pediculed transverse rectus abdominis myocutaneous flap (TRAM). So, in all, 1100 immediate breast reconstruction with either a prosthesis or a pediculed flap were performed. The specialised teams aim is to use the TRAM free transplant for immediate breast reconstruction. Between 1990 to 1995 we have performed 5 free TRAM for breast reconstruction for cancer and 6 TURBOTRAM. It is important for the woman to have an abdominal adiposity, to be able to give an excellent breast. Four out of five of the free TRAM reconstructions were successful and one give partial necrosis (4 x 4 cm). All the 6 TURBOTRAM operations were uneventful. There are many advantages with this technique: the free TRAM allows a large resection of the thoracic skin and gives a natural form to the breast, without any prosthesis. The taking of the free TRAM gives only few abdominal hernia and realize an abdominoplasty. Our aim is to perform immediate breast reconstruction with free TRAM flap.

[Efficacy of massage and mobilization of the upper limb after surgical treatment of breast cancer]. / Efficacité du massage et de la mobilisation du membre supérieur après traitement chirurgical du cancer du sein.

We have compared different modes of rehabilitation after breast cancer surgery on a population of 257 patients treated at the Institute Gustave-Roussy in 1990 and 1991. The mode of rehabilitation was randomized according to a 2 X 2 design, between physiotherapy alone, shoulder movement alone, both or neither. Treatment began the day after breast surgery and continued for 7 days. Afterwards, all patients had physiotherapy and shoulder movements until the end of hospitalisation. Treatment efficacy was evaluated at day 7 by the volume of lymph drained, and by degree of shoulder movement. The volume of lymph collected by day 7 was reduced in the physiotherapy groups, but was not modified in the groups with shoulder movement. The degree of motion was larger in the group who had had both physiotherapy and shoulder movement. The frequencies of complications at day 7 and later were similar in the four treatment groups, but locoregional pain was less frequent in the two groups with shoulder movement than in the two other groups. An early treatment including both physiotherapy and shoulder movement seems advisable.

[Role of immediate reduction mammaplasty and mammapexy in the conservative treatment of breast cancers]. / Place des réductions et pexies mammaires immédiates dans le traitement conservateur des cancers du sein.

For some years, breast cancer surgery has become increasingly conservative, in order to preserve the aesthetic aspect of the treated breast and global harmony of the bosom. Unfortunately, conservative treatment is followed by 20% to 30% of unsatisfactory cosmetic results. Some studies have defined the various factors associated with an increased failure rate in terms of cosmetic results. These are related to the surgical technique, patient characteristics, or tumor specificities. In these cases with a poor aesthetic prognosis, the authors propose, following the initial tumorectomy, esther breast reduction or mammaexy, in order to reshape the volume of the breast as symmetrically as possible. In a series of 21 female patients operated at the Institut Gustave-Roussy between 1988 and 1991, the authors describe the aesthetic and carcinologic advantages of this method, and define its main indications. Although the aesthetic aspect of the operated breast was considered tube excellent in 33% of cases and good in 67% of cases, the global harmony of the breasts was excellent or good in 76% of cases. The 24 moderate or poor results were due to asymmetry of shape or volume, which is easy to improve by a secondary contralateral breast reduction.

[Intraductal carcinoma of the breast (DCIS). Should the treatment be conservative or not?]. / Le carcinome intracanalaire du sein (CCIS). Le traitement doit-il être conservateur ou non?

Due to systematic mammography, DCIS is being seen with increased incidence than in the past. Asymptomatic women screened by mammography show a high incidence of microcalcifications. Lymph node involvement is seen in very few patients. Total mastectomy provides local control and long term survival approaching 100%. Immediate breast reconstruction allows better acceptance of mutilations. Conservative treatment has been advocated for localised DCIS. The classification system dividing DCIS into comedo- and non-comedo subtypes could be an oversimplification because of the frequent histological heterogeneity. Other criteria such as cytological features oncogene activity of C erb 2 and clinical and radiological features must be considered. It has now been demonstrated that DCIS does not have a multicentric distribution. Assessment of lesion size appears to be primordial for breast conservative treatment indications. A relationship has been demonstrated between lesion size and microinvasion. The aim is complete excision with free margins and a cosmetically acceptable postoperative result. Radiotherapy seems to lower the incidence of local recurrences in retrospectives studies. Prospective randomized trials are being conducted to compare lumpectomy with and without radiotherapy.

Risk factors for failure of immediate breast reconstruction with prosthesis after total mastectomy for breast cancer.

BACKGROUND: Immediate breast reconstruction (IBR) after mastectomy represents a clear improvement in the quality of life of patients with breast cancer, but prosthesis removal is relatively frequent. Therefore, it is important to identify risk factors related to this removal. METHODS: A series of 142 patients treated with mastectomy and IBR at the Institut Gustave-Roussy between January 1976 and December 1988 were studied. Forty-seven had an in situ carcinoma, 93 an infiltrating carcinoma, and 2 a fibrosarcoma. IBR failures were defined as removal of the prosthesis, and early failures as removal during the first 7 weeks after IBR. RESULTS: The early failure rate was significantly higher in patients with invasive carcinomas or fibrosarcomas than patients with in situ carcinomas (12% versus 0%, P = 0.04). The risk of late IBR failure was significantly higher in patients who had received postoperative radiation therapy than patients who did not (P = 0.0002). However, this increased risk applied only to women in whom the chest wall was exposed to radiation because of a high risk of recurrence. CONCLUSION: It might be preferable to postpone breast reconstruction for patients with infiltrating breast carcinoma because early complications are not infrequent and could delay adjuvant chemotherapy. Late complications associated with chest wall irradiation could be avoided with the use of alternative techniques such as the transverse rectus abdominis myocutaneous (TRAM) flap procedure.

[Immediate breast reconstruction: indications and technics. Apropos of 120 cases treated at the Institut Gustave-Roussy]. / La reconstruction mammaire immédiate: indications et techniques. A propos de 120 cas réalisés à l'Institut Gustave-Roussy.

From 1976 to 1986 one hundred and twenty immediate breast reconstructions (IBR) were performed at the Gustave-Roussy Institut. 90% of these cases were treated for in situ or infiltrating carcinomas, while only 10% had prophylactic mastectomy. Over recent decades indications for IBR have progressively changed. In the first period they were reserved for prophylactic mastectomies and in situ carcinomas. Over the last several years IBR has also been proposed to patients with infiltrating carcinomas (30%). Although the adequate treatment for small invasive carcinomas is a radiosurgical conservative procedure, a mastectomy is still indicated in stage II, over three centimeters multifocal carcinomas, and local recurrence after conservative treatment. In our series, this procedure seems safe and advisable as it does not interfere with the treatment of primary and secondary disease. The low incidence of surgical complications reported in our series did not increase the hospital stay of our patients. Indications, surgical techniques including myocutaneous flaps, and results of IBR will be discussed.