Comparison of models to predict nonsentinel lymph node status in breast cancer patients with metastatic sentinel lymph nodes: a prospective multicenter study.

PURPOSE: Several models have been developed to predict nonsentinel lymph node (non-SN) status in patients with breast cancer with sentinel lymph node (SN) metastasis. The purpose of our investigation was to compare available models in a prospective, multicenter study. PATIENTS AND METHODS: In a cohort of 561 positive-SN patients who underwent axillary lymph node dissection, we evaluated the areas under the receiver operating characteristic curves (AUCs), calibration, rates of false negatives (FN), and number of patients in the group at low risk for non-SN calculated from nine models. We also evaluated these parameters in the subgroup of patients with micrometastasis or isolated tumor cells (ITC) in the SN. RESULTS: At least one non-SN was metastatic in 147 patients (26.2%). Only two of nine models had an AUC greater than 0.75. Three models were well calibrated. Two models yielded an FN rate less than 5%. Three models were able to assign more than a third of patients in the low-risk group. Overall, the Memorial Sloan-Kettering Cancer Center nomogram and Tenon score outperform other methods for all patients, including the subgroup of patients with only SN micrometastases or ITC. CONCLUSION: Our study suggests that all models do not perform equally, especially for the subgroup of patients with only micrometastasis or ITC in the SN. We point out available evaluation methods to assess their performance and provide guidance for clinical practice.

Prevalence and predictive factors for the detection of carcinoma in cavity margin performed at the time of breast lumpectomy.

Margin resection status is a major risk factor for the development of local recurrence in breast conservation therapy for carcinoma. Tumor bed excision sent as separate orientated cavity margins represents a tool to verify the completeness of the carcinoma resection. We aimed to (1) determine the prevalence of positive cavity margin and its influence on subsequent surgical treatment and (2) identify potential predictive factors for positive cavity margins. From 2003 to 2006, 107 (57 years; 30-88) consecutive patients who underwent a lumpectomy for carcinoma with four orientated cavity margins for carcinoma were selected. Preoperative clinical, radiological and histological data, perioperative macroscopic characteristics and definitive histological analysis results were recorded. Lumpectomy or cavity margins were considered as positive when the distance from carcinoma to the margin was less than or equal to 3 mm. Histological examination of cavity margins showed carcinoma in 38 patients (35%), therefore modifying subsequent surgical therapy in 33 cases. Examination of the cavity margins led (1) to avoiding surgical re-excision in 20 cases (lumpectomy margins were positive and the cavity margins negative), (2) to performing a mastectomy or a re-excision in 13 cases (carcinoma was detected in the cavity margins although the lumpectomy margins were negative or tumor size was superior to 3 cm). Between preoperative and perioperative parameters, US scan and macroscopic size of the tumor were predictive factors for positive cavity margins whereas characteristics of the carcinoma determined on biopsy samples and macroscopic status of the lumpectomy margins were not. Our study confirms that the systematic practice of cavity margin resection avoids surgical re-excision and reduces the likelihood of underestimating the extent of the tumor.

Validation of the Tenon breast cancer score for predicting non-sentinel lymph node status in breast cancer patients with sentinel lymph node metastasis: a prospective multicenter study.

BACKGROUND: Axillary lymph node dissection (ALND) is the standard treatment for patients with sentinel node (SN) metastasis, but most of these patients have negative non-sentinel nodes (non-SN). We have developed a scoring system (the Tenon score) to help identify a subgroup of patients who have a low risk of having non-SN metastases and who may thus forgo ALND. Here we validated the Tenon score in an independent cohort of SN-positive patients. PATIENTS AND METHODS: We tested the accuracy of the Tenon score for predicting non-SN status in a prospective multicenter study of 226 SN-positive breast cancer patients. We calculated the false-negative rate, sensitivity, specificity, and positive (PPV) and negative predictive values (NPV). Receiver operating characteristics (ROC) curves were constructed and the areas under the curve (AUC) were calculated as a measure of discriminatory capacity. RESULTS: At least one non-SN was positive in 63 patients (27.9%). One hundred and twenty (53.1%) of the 226 patients had a Tenon score of 3.5 or less. Among these 120 patients, five had at least one positive non-SN. With a score cut-off of 3.5, the negative predictive value was 95.8% and the false-negative rate was 4.2%. Overall, the Tenon score accurately predicted non-SN status, with an AUC of 0.82 (95% confidence interval, 0.77-0.88). CONCLUSION: In this multicenter study of an independent patient population, the Tenon score was accurate and reproducible for predicting non-SN status in breast cancer patients. The simplicity and reliability of the variables on which the Tenon score is based may be an advantage over other scoring systems.

Preoperative concurrent radiation therapy and chemotherapy for bulky stage IB2, IIA, and IIB carcinoma of the uterine cervix with proximal parametrial invasion.

PURPOSE: To evaluate toxicity, local tumor control, and survival after preoperative chemoradiation for operable bulky cervical carcinoma. METHODS AND MATERIALS: Between December 1991 and July 2006, 92 patients with operable bulky stage IB2, IIA, and IIB cervical carcinoma without pelvic or para-aortic nodes on pretreatment imaging were treated. Treatment consisted of preoperative external beam pelvic radiation therapy (EBRT) and concomitant chemotherapy (CT) during the first and fourth weeks of radiation combining 5-fluorouracil and cisplatin. The pelvic radiation dose was 40.5 Gy over 4.5 weeks. EBRT was followed by low-dose rate uterovaginal brachytherapy with a total dose of 20 Gy in 62 patients. After a median rest period of 44 days, all patients underwent Class II modified radical hysterectomy with bilateral pelvic lymphadenectomy. Thirty patients who had not received preoperative uterovaginal brachytherapy underwent postoperative low-dose-rate vaginal brachytherapy at a dose of 20 Gy. The mean follow-up was 46 months. RESULTS: Pathologic residual tumor was observed in 43 patients. After multivariate analysis, additional preoperative uterovaginal brachytherapy was the single significant predictive factor for pathologic complete response rate (p = 0.019). The 2- and 5-year disease-free survival (DFS) rates were 80.4% and 72.2%, respectively. Pathologic residual cervical tumor was the single independent factor decreasing the probability of DFS (p = 0.020). Acute toxicities were moderate. Two severe ureteral complications requiring surgical intervention were observed. CONCLUSIONS: Concomitant chemoradiation followed by surgery for operable bulky stage I-II cervical carcinoma without clinical lymph node involvement can be used with acceptable toxicity. Pathologic complete response increases the probability of DFS.

Various Doppler sonographic appearances and challenges in prenatal diagnosis of vasa praevia.

Rupture of vasa praevia is associated with a high rate of fetal or neonatal mortality. Since the recent development of color and spectral Doppler sonography, prenatal diagnosis of vasa praevia has been increasing but is not yet consistent. We report 2 cases that were diagnosed prenatally, enabling cesarean section to be performed under optimal conditions to prevent complications. A better knowledge of the characteristic Doppler sonographic appearances and the risk factors associated with vasa praevia could greatly facilitate the prenatal diagnosis of this condition and hence the fetal prognosis.

[Indication for labor induction by prostaglandin E2 vaginal gel. Retrospective study of a continuous series of 170 patients]. / Indication de l'induction du travail par gel vaginal de prostaglandine E2. Etude rétrospective d'une série continue de 170 patientes.

OBJECTIVE: To assess the factors of efficacy, side effects and complications following vaginal application of prostaglandin E2 (PGE2). METHODS: Retrospective study of 170 women in whom a PGE2 vaginal gel was administered between June 1, 1999 and June 1, 2000. The efficacy (labor effectively induced), quality of myometrial response, side effects and complications were studied globally and in each clinical context: intra-uterine delayed growth (IUDG), pre-eclampsia without IUDG, diabetes, pregnancy prolonged without IUDG, anomaly in fetal heart rate (FHR) and/or in amniotic liquid without IUDG discovered during the systematic monitoring at the end of pregnancy, premature rupture of the membrane without IUDG. RESULTS: The overall success (defined as the onset of labor) was of 94.1%. This rate was of 90.7% in primiparous and of 100% in multiparous women. Twenty-three patients (13.5%) experienced side effects (hyperkinesia or hyperthermia) and 35 patients (20.6%) complications (hyperkinesia or hypertonia with fetal repercussion). The maternal-response to infection was significantly improved (p < 0.05) in cases of prolonged rupture of the membranes or anomaly discovered during monitoring, but only in patients with diabetes. In cases of IUDG of vascular etiology with multiparity, the total quantity of PGE2 necessary was only of 1.14 mg and 85% of patients subsequently delivered without ocytocine. CONCLUSION: IUDG and prolonged pregnancy are the principle indications for PGE2 vaginal gels. The quality of response depends on the clinical context. In cases of premature rupture of the membranes or of anomaly discovered during monitoring (FHR and amniotic liquid), response was only improved in diabetic patients. In cases of vascular IUDG and multiparity, the response was excellent and the majority of women subsequently delivered without ocytocine, thus confirming the quality of myometrial response. Hence, the quantity of PGE2 required varied, depending on the subjecent pathology. This strategy could limit the risk of excessive myometrial response (hyperkinesia or hypertonia) and thus improve fetal tolerance.