Sentinel node involvement with or without completion axillary lymph node dissection: treatment and pathologic results of randomized SERC trial.

Based on results of clinical trials, completion ALND (cALND) is frequently not performed for patients with breast conservation therapy and one or two involved sentinel nodes (SN) by micro- or macro-metastases. However, there were limitations despite a conclusion of non-inferiority for cALND omission. No trial had included patients with SN macro-metastases and total mastectomy or with >2 SN macro-metastases. The aim of the study was too analyze treatment delivered and pathologic results of patients included in SERC trial. SERC trial is a multicenter randomized non-inferiority phase-3 trial comparing no cALND with cALND in cT0-1-2, cN0 patients with SN ITC (isolated tumor cells) or micro-metastases or macro-metastases, mastectomy or breast conservative surgery. We randomized 1855 patients, 929 to receive cALND and 926 SLNB alone. No significant differences in patient's and tumor characteristics, type of surgery, and adjuvant chemotherapy (AC) were observed between the two arms. Rates of involved SN nodes by ITC, micro-metastases, and macro-metastases were 5.91%, 28.12%, and 65.97%, respectively, without significant difference between two arms for all criteria. In multivariate analysis, two factors were associated with higher positive non-SN rate: no AC versus AC administered after ALND (OR = 3.32, p < 0.0001) and >2 involved SN versus ≤2 (OR = 3.45, p = 0.0258). Crude rates of positive NSN were 17.62% (74/420) and 26.45% (73/276) for patient's eligible and non-eligible to ACOSOG-Z0011 trial. No significant differences in patient's and tumor characteristics and treatment delivered were observed between the two arms. Higher positive-NSN rate was observed for patients with AC performed after ALND (17.65% for SN micro-metastases, 35.22% for SN macro-metastases) in comparison with AC administered before ALND.

Assessment of the Grisotti oncoplastic procedure for the management of central breast tumors.

INTRODUCTION: The Grisotti technique consists to excise central breast tumor with nipple areolar and mobilize a dermo-glandular flap which is de-epithelized in order to reshape the breast and recreate an areola. The objective was to assess oncological results, postoperative side-effects, and patient and surgeon satisfaction rates resulting from this technique. MATERIALS AND METHODS: From September 2016 to December 2019, 38 patients have been treated with a central breast tumor using the Grisotti technique. RESULTS: The mean age was 61.6 ± 11. The median body mass index was 27 kg/m² [20-42]. Thirty one patients benefited from a sentinel lymph node dissection. Preoperative histology found a majority of invasive ductal carcinomas (IDC) (71%). There were no intraoperative complications, and the average operating time was 90 min [60-200]. Postoperative histology found IDC associated with ductal carcinoma in situ in 28 patients. The surgical margins were invaded in two patients (reoperated by mastectomy after adjuvant treatment) and invasion of a margin of less than 1 mm in another six patients (supplemented by re-excision). The main postoperative complications were an abscess of the operating site and a partial necrosis of the neo-areola. The appearance of the breasts after radiotherapy gives a high satisfaction rate, both for patients and for surgeons. CONCLUSION: The Grisotti technique is an easily reproducible procedure without major complications. It makes it possible to perform a carcinological satisfactory central lumpectomy, correction of the central glandular defect, and reconstruction of a new areola.

Ecchymotic Purpura of the Breast Revealing a Locally Advanced Breast Cancer: An Exceptional Presentation of a Carcinomatous Mastitis.

A 79-year-old woman was treated at our department for a neoplasm of the left breast. It was discovered following the spontaneous appearance of a localized ecchymotic lesion of the breast. The only clinical sign was this purpura, with no notion of trauma. The lesion was homogeneous, oval, and measuring 4 × 5 cm, and it was stable for 2 months. The patient had no history of thrombocytopenia and no known allergy. The physical examination was not very helpful and did not find any palpable breast lesion besides a 1-cm left axillary lymphadenopathy. Breast screening revealed a solid, poorly delineated structure of 11 mm. Biopsies were taken and revealed a NOS grade II invasive carcinoma, triple negative, with a Ki-67 proliferation index of 15%. The axillary cytology was positive. Faced with this atypical presentation, a skin biopsy was performed on the bruise in order to exclude skin invasion. Histology showed the presence of carcinomatous lymphatic dermal emboli which could correspond to a mammary origin as well as extravasation of blood in the dermis explaining this ecchymotic aspect. Bone scintigraphy found discrete uptake in the rib cage, spine, and pelvis, suspicious in this context, but a benign origin could not be ruled out. Neoadjuvant chemotherapy was initiated before mastectomy and left axillary node dissection. It was an atypical and rare clinical presentation of advanced breast cancer with no similar case found in the literature. Usually, the presence of emboli with carcinomatous cells obstructing the lymphatic vessels is related to inflammatory breast cancer or carcinomatous mastitis. The authors nevertheless point out that although the presence of tumor emboli in the dermal lymphatic vessels is favorable to the diagnosis, it is not required. In addition, dermal lymphatic invasion without a typical clinical presentation is not sufficient to confirm the diagnosis of carcinomatous mastitis. An important diagnostic criterion is the rapidity of aggravation of the symptoms, which, even if it was not obvious in our case, was present with progressive evolution of the skin lesion over several weeks. The skin lesion of our patient could also make us suspect a primary breast angiosarcoma. This possibility was quickly eliminated in the absence of vascular tumor proliferation on the various biopsies. Any acute purpura is a serious disease to be diagnosed urgently, and a skin biopsy is indicated.

External Validation of the SERC Trial Population: Comparison with the Multicenter French Cohort, the Swedish and SENOMIC Trial Populations for Breast Cancer Patients with Sentinel Node Micro-Metastasis.

Many trials confirmed the safety of omitting axillary dissection in the selected patients treated for early breast cancer. The external validity of these trials is questionable. Our study aimed to evaluate the accuracy of the French population representativity in the SERC trial and the differences between these two populations as well as comparing the French and the Swedish populations (the SENOMIC trial population and the Swedish National Breast Cancer Registry (NKBC) cohort) of patients with sentinel node (SN) micro-metastasis. A higher rate of smaller tumors and grade 1 tumors was observed in the French cohort when compared to the SERC population. Our findings conclude that both French populations show similar characteristics. Positive non-sentinel node (NSN) rates at completion axillary lymph node dissection (ALND) were 10.28 % and 11.3 % in the SERC trial and French cohort, respectively (p = 0.5). The rate of grade 1 tumors was lower in the SENOMIC trial (16.2%) and in the NKBC cohort (17.4%) compared to the SERC trial population (27.3%) and the French cohort (34.4%). Our findings in addition to the previously demonstrated concordance between the SENOMIC trial and the NKBC populations imply that the results of both the SERC and the SENOMIC trials can be applied to both French and Swedish real populations.

Overview of the pathological results and treatment characteristics in the first 1000 patients randomized in the SERC trial: axillary dissection versus no axillary dissection in patients with involved sentinel node.

BACKGROUND: Three randomized trials have concluded at non inferiority of omission of complementary axillary lymph node dissection (cALND) for patients with involved sentinel node (SN). However, we can outline strong limitations of these trials to validate this attitude with a high scientific level. We designed the SERC randomized trial ( ClinicalTrials.gov , number NCT01717131) to compare outcomes in patients with SN involvement treated with ALND or no further axillary treatment. The aim of this study was to analyze results of the first 1000 patients included. METHODS: SERC trial is a multicenter non-inferiority phase 3 trial. Multivariate logistic regression analysis was used to identify independent factors associated with adjuvant chemotherapy administration and non-sentinel node (NSN) involvement. RESULTS: Of the 963 patients included in the analysis set, 478 were randomized to receive cALND and 485 SLNB alone. All patient demographics and tumor characteristics were balanced between the two arms. SN ITC was present in 6.3% patients (57/903), micro metastases in 33.0% (298), macro metastases in 60.7% (548) and 289 (34.2%) were non eligible to Z0011 trial criteria. Whole breast or chest wall irradiation was delivered in 95.9% (896/934) of patients, adjuvant chemotherapy in 69.5% (644/926), endocrine therapy in 89.6% (673/751) and the proportions were similar in the two arms. The overall rate of positive NSN was 19% (84/442) for patients with cALND. Crude rates of positive NSN according to SN status were 4.5% for ITC (1/22), 9.5% for micro metastases (13/137), 23.9% for macro metastases (61/255) and were respectively 29.36% (64/218), 9.33% (7/75) and 7.94% (10/126) when chemotherapy was administered after cALND, before cALND and for patients without chemotherapy. CONCLUSION: The main objective of SERC trial is to demonstrate non inferiority of cALND omission. A strong interaction between timing of cALND and chemotherapy with positive NSN rate was observed. TRIAL REGISTRATION: This study is registered with ClinicalTrials.gov , number NCT01717131 October 19, 2012.

[Migration of an intra uterine device into the bladder]. / Migration intravésicale d'un dispositif intra-utérin. Stratégies d'exploration et modalités thérapeutiques.

The migration of an intra uterine device (IUCD) into the bladder is a rare complication. The authors report a case of IUCD migrated into the bladder. The patient was asymptomatic. Diagnosis was made on abdominal X-ray performed for another reason. It was confirmed by ultrasound and cystoscopy. As the IUCD was only partially intra vesical, it's removal was made by laparoscopy and cystoscopy. The authors then discussed the frequency, the physiopathology, the diagnosis and the treatment with arguments from the literature.