[How to manage late periprosthetic fluid collections (seromas) in patients with breast implants?] / Conduite à tenir devant un sérome tardif péri-prothétique.

The widespread use of silicone implants in reconstructive and aesthetic breast surgery led to an increase in the incidence of breast implant associated anaplastic large cell lymphoma, BIA-ALCL, mainly associated with the use of macro-textured breast implants. BIA-ALCL is a serious complication presenting clinically as a late onset periprosthetic seroma. Thus, its occurrence became an alarming sign feared by most plastic surgeons. Therefore, a good knowledge with respect to early diagnosis, subsequent workup, and treatment is crucial in the management of periprosthetic seroma. The diagnosis of late onset seroma is clinically evident. Although idiopathic seroma is the most common cause, BIA-ALCL should be always eliminated. A complete workup is usually necessary. An ultrasound performed by a radiologist specialized in breast imaging followed by an ultrasound guided puncture is imperative. Consequently, the cytological and the bacteriological analysis will orient us toward the etiology (infectious, neoplastic or mechanical). A standardized management of late periprosthetic seroma does not exist, with various factors are to be taken into consideration. These include the surgeon's experience, the diagnosis, and the medical institution facilities. Although idiopathic seroma is managed by a simple puncture and drainage, other causes may require a surgical procedure with implant removal, capsulotomies, and/or total capsulectomies.

[Breast implant-associated anaplastic large cell lymphoma. Case report of an undiagnosed form, management and reconstruction (ALCL)]. / Lymphome anaplasique à grandes cellules associé aux implants mammaires (LAGC-AIM). Présentation clinique d'une forme initialement non-diagnostiquée, prise en charge et reconstruction.

Breast implant-associated anaplastic large cell lymphoma (ALCL) is an extremely rare disease. Is a new nosologic entity with a multifactorial origin and a wide occurrence delay after breast implantation. This article reports the case of a 60 years old patient with a progressive swelling of the right breast after aesthetic breast implants. Diagnostic was delayed because first surgeon was not familiar with the disease. Patient was then referred to us for management. We performed an implant removal and a complete capsulectomy. Pathologic report confirms the diagnostic. After one year and normal ultrasound evaluation, we reconstructed the breast with lipomodeling and mastopexy. Contralateral implant was also removed at time of reconstruction. Vast majority of breast implant-associated ALCL occurs at a time lapse of 11 to 15 years after implant augmentation, with a mean age of 63 years. Among the worldwide 173 cases reported in March 2015, smooth implants seem not to be at risk but 80% of cases were associated with macrotexturized implants. Clinical presentation and diagnostic tools are more and more published but there is to date no recommendation concerning reconstruction delay after implant removal for this pathology. We advise the realization of a breast ultrasound every three months during the first year and wait for a one-year period before reconstruction. In case of aesthetic surgery, mastopexia can be done to allow for glandular shaping. Lipomodeling is an excellent technique to correct the lack of volume due to implant removal. In case of reconstructive setting, implant can be replaced by flap procedure with lipomodeling if needed or lipomodeling alone if recipient site is favorable and patient has enough fat tissue. Contralateral implant should be removed during reconstruction time.

[Long-term outcome of lipomodeling in Poland's syndrome: about our first case with an eleven-years' follow-up]. / Évolution de la reconstruction mammaire par lipomodelage dans le syndrome de Poland: à propos d'un cas avec un recul de onze ans.

Poland's syndrome is a rare congenital malformation with thoracic and breast deformities very difficult to treat. Several techniques can be used involving, sometimes, implant insertion. Most of the classic techniques could not be used in this patient. Particularly, the transfer of the latissimus dorsi flap could not be performed because of the agenesis of the muscle. Lipomodeling is used, in our team, for breast reconstruction since 1998. This case was described and published one year after the end of the reconstruction in 2004. The immediate outcome appeared very satisfying and effective but some surgeons remained skeptical. An important question remains: what about the long-term efficiency and stability of the reconstruction? In this review, we report our first case of severe Poland's syndrome treated eleven years ago with lipomodeling. The patient was twelve years old. She had a severe form of Poland's syndrome. Five fat grafting sessions were performed between 2001 and 2003, for a total transfer of 809 ml. Today, outcome is very satisfying with a natural breast shape, consistency and sensitivity. An increase of volume in the reconstructed breast is noted. It is due to a rapid and significant weight gain by the patient. We performed two shorts movies describing this outcome one year and ten years after the reconstruction. It confirms the stability and the sustainability of the reconstruction. Lipomodeling does not interfere with breast ultrasound surveillance. Fat grafting deeply improved outcomes and management of thoracic and breast deformities in Poland's syndrome.

Preoperative imaging prior to breast reconstruction surgery: benchmarking bringing together radiologists and plastic surgeons. Proposed guidelines.

BACKGROUND: Prescription of preoperatory imaging assessment prior to planned breast reconstruction surgery (reduction or augmentation mastoplasty, correction of congenital breast asymmetry) is poorly codified. The objective of this study was to analyze the attitudes of French radiologists and plastic surgeons with regard to prescription of preoperative imaging in the framework of non-oncologic breast surgery. MATERIAL AND METHODS: This is a descriptive and comparative observational study involving two groups, one consisting of 50 plastic surgeons (P) and the other of 50 radiologists (R) specialized in breast imaging. A questionnaire was handed out to radiologists during a conference on breast imaging at the Institut Gustave-Roussy in Paris (France) held on 17th December 2012. The same questionnaire was handed out to plastic surgeons at the National Congress of the French Society of Plastic and Reconstructive Surgery (SOFCPRE) held on 19th, 20th and 21st November 2012, also in Paris (France). The questionnaire focused on prescription of preoperative and postoperative imaging evaluation for non-oncologic breast surgery in patients with no risk factors for breast cancer or clinically identified indications. RESULTS: Forty-six percent of the plastic surgeons considered an imaging exam to be recent when it had been carried out over the previous 6 months, while 40% of the radiologists set the figure at 1 year. Clinical breast density exerted no influence on 92% of the plastic surgeons and 98% of the radiologists. A majority of the plastic surgeons would prescribe a preoperative exam regardless of age (57% for breast reduction, 61% for breast implant placement and 61% for surgical correction of asymmetry) while the radiologists would prescribe exams mainly for patients over 40 years (50% for reduction, 44% for augmentation, 49% for asymmetry correction). The plastic surgeons would prescribe either ultrasound or mammograms (59% for reduction, 72% for augmentation, 66% for asymmetry correction) while radiologists would usually prescribe mammograms (64%, 57%, 64%). Most of the radiologists, along with the plastic surgeons, did not think that postoperative examination is justified (58% of P and 62% of R for reduction, 56% P and 68% of R for augmentation, 52% of P and 64% of R for asymmetry correction). CONCLUSION: In 2012, there existed no French consensus on prescription of a preoperative imaging assessment in the framework of non-oncologic breast surgery in patients without risk factors for breast cancer. Active cooperation bringing together radiologists and plastic surgeons is likely to facilitate the harmonizing of their respective practices. In this paper, we propose guidelines that could help them to synchronize their efforts.

Radio-histological correlations of subtle sonography images.

Breast lesions may, during their development, provide sonography signs can be difficult to view or are not very specific. They are called "subtle images". Proximal (ductal) lesions are differentiated from distal (ductal-lobular) lesions. Proximal lesions are mainly inflammatory or infectious, altering the duct walls that evolve into ectasia and then fibrosis with possible acute episodes of plasmocyte mastitis or bacterial mastitis. The fibrovascular stalks of the papilloma accounts for the Doppler flow. Certain secretory forms of intra-ductal carcinoma may distend the structure of the milk ducts. The sonography of lesions of the ductal-lobular units are related to the degree of fibrosis, the atrophy or cell proliferation, and the disorganisation of the architecture. The extent of the fibrosis, or the cell density of certain tumours may modify the tissue hardness in elastography.

[Value of stereotactic breast core biopsy in patients with atypical ductal hyperplasia]. / Valeur des macrobiopsies mammaires sous guidage stéréotaxique en cas de découverte d'une hyperplasie canalaire atypique.

PURPOSE: Based on a dual center retrospective study, the risks of under-diagnosing clusters of microcalcifications on core biopsies are analyzed. Imaging and histopathological factors affecting this risk are explored. MATERIALS AND METHODS: A total of 1,400 lesions (ACR BI-RADS 2-5) were reviewed and analyzed for size, degree of excision (%), and histology result. A total of 381 patients underwent surgery. Inter-center review of some histological slides was also performed. RESULTS: The rate of under-diagnosis was 5.9% for ductal carcinoma in-situ (DCIS) and 12.5% for atypical ductal hyperplasia (ADH). Most cases of under-diagnosis involved clusters larger than 20 mm in diameter where the percentage of excision decreased from 98% (clusters<10 mm) to 9%. Review of histological slides showed inter-observer variability that decreased in relation to experience. ADH was never under-diagnosed when 3 or less foci were present. The risk of under-diagnosis for DCIS increased when the number of biopsies containing DCIS was superior to 50% and if the grade was high. CONCLUSION: The presence of ADH on biopsy specimens requires surgical biopsy, but optimal core biopsies with cluster removal and histological analysis by an experienced observer allows identification of low risk patients that could undergo close follow-up.

[Lipomodelling for correction of breast conservative treatment sequelae. Medicolegal aspects. Expert opinion on five problematic clinical cases]. / Lipomodelage et correction des séquelles du traitement conservateur du cancer du sein Aspects médicolégaux. Le point de vue de l'expert à partir de cinq cas cliniques délicats.

In our unit, breast cancer patients suffering mild sequelae of conservative cancer treatment receive fat transfer (lipomodelling), following a precise protocol, based on mammographic and ultrasound examinations and MRI. Available data do not seem to indicate any deleterious impact on patient outcome, notably in view of radiological images, but recurrence (or rather occurrence of new ipsilateral or contralateral cancer) is frequent. The correlation between new or recurrent breast cancer and lipomodelling is high; misinterpretations are possible and frequently arise. The present paper is a description of five complex clinical cases and a discussion of the medicolegal issues that may possibly arise; it also provides tentative expert evaluation of the cases. Clinical findings are reported and analyzed. The second step is a discussion of the radiological impact of lipomodelling, and of the problems caused by the transfer of potentially malignant cells when no preoperative diagnosis of recurrence is made; the morphological and esthetic benefits of the method are described, as well as the potential beneficial impact of fat transfer, notably associated with lower breast density and injections of fat stem cells. Our conclusion is that specialized radiologists, as well as plastic surgery and oncology experts should address the question of fat transfer in operated breast cancer patients and give their reasoned opinion about potentially litigious cases. This would help minimize or solve the conflicts between patients, doctors and experts. Establishing common ground between the different stakeholders would allow the development of the technique, as lipomodelling is, according to our experience, a tremendous advance in the treatment of sequelae from conservative breast cancer surgery.

[Breast pilomatrixoma manifested as microcalcifications on mammography: report of two cases]. / Pilomatricomes mammaires révélés par des microcalcifications à la mammographie: à propos de deux cas.

Pilomatricoma is a benign tumor of hair follicule origin corresponding to a firm subcutaneous nodule requiring histology for diagnosis. Only few breast pilomatricomas have been reported, with imaging showing well defined nodules with microcalcifications. We report two cases of intra-mammary pilomatricomas presenting as ACR BI-RADS 4 and 5 microcalcifications, suspicious for malignant tumors. Percutaneous biopsy confirmed the histological diagnosis. Malignant pilomatricomas have been reported, suggesting that all pilomatricomas should be resected.

[Value of vacuum assisted biopsies under sonography guidance: results from a multicentric study of 650 lesions]. / Place des macrobiopsies mammaires assistées par le vide sous guidage échographique: étude multi-centrique de 650 lésions.

OBJECTIVE: With this retrospective, multi-centric study, the authors are showing the technique of Vacuum assisted biopsies under ultrasound guidance and comparing it with the other widely used diagnostic techniques. Material and method. Six hundred and fifty biopsies were performed between May 2000 and December 2004, on 644 patients, in 3 centres, following a unique protocol. Lesions were categorized, using the classification from Stavros, between "probably benign", "indeterminate", "probably malignant" and "malignant" Histology was validated only after review of the clinical and radiological data, as well as surgical data when available. All benign cases were included in an on-going follow-up protocol. RESULTS: We have identified 471 benign lesions and 179 malignant lesions. The mean size of the lesions was 9 mm. Three cancers were diagnosed in the cases of "probably benign lesions" and in the cases of "probably malignant lesions" 18 (27%) were inflammatory disorders. In 5 cases vacuum biopsy underestimated the pathology with regard to surgery: 2 cases of atypical duct hyperplasia (HCA) were in situ ductal carcinoma (DCIS) at surgery and 3 cases of DCIS were infiltrative ductal carcinoma (DCI) at surgery. With this technique we have avoided surgery for 71% of all women who presented an "indeterminate" or "probably malignant" condition. Specificity is excellent with no cancer detected so far among the patients with benign findings, under follow-up. CONCLUSION: Ultrasound guided Vacuum assisted biopsy is a fairly recent minimally invasive technique, with short learning curve. The ability to collect a larger volume of tissue overcomes the targeting issues on small lesions and avoids underestimation of heterogeneous and larger abnormalities and some specific at-risk lesions such as papilloma. This technique thus appears indicated in such cases because it overcomes some of the limitations of core needle biopsy and should be considered as an alternative to surgical biopsy.

[Portasystemic anastomosis by transjugular approach: treatment of active and refractory hemorrhage caused by rupture of esophageal varices. Results in 11 patients]. / Anastomose porto-systémique par voie transjugulaire: traitement de l'hémorragie par rupture de varices oesophagiennes active et réfractaire. Résultats chez 11 malades.

OBJECTIVE: The aim of this study was to assess the feasibility and efficacy of transjugular intrahepatic portosystemic shunts for refractory variceal bleeding, uncontrolled by sclerotherapy or endoscopic ligation. METHODS: 11 patients (mean age: 52 years) with cirrhosis admitted for refractory haemorrhage from ruptured oesophageal varices were included in this study. Eight patients were Child-Pugh class C. All patients were actively bleeding. RESULTS: All the procedures were successful. Variceal haemorrhage stopped within 24 h. There was no mortality during the procedure. Early complications such as rebleeding (18%) and thrombosis (18%) occurred. Thirty days mortality was 27%. Follow-up in the 8 surviving patients was 19.5 +/- 8 months. Three patients developed recurrent bleeding, from non-variceal sources in 2. In 4 surviving patients, occlusion of the shunt was treated with dilatation or insertion of a second stent. The incidence of hepatic encephalopathy was 25%. Five patients subsequently underwent liver transplantation. Among the 3 patients ineligible for transplantation, one died of hepatocellular carcinoma after 10 months. The 2 others were alive after 19 and 25 months, respectively. CONCLUSIONS: These results suggest that transjugular intrahepatic portosystemic shunt is a safe and effective procedure of portal decompression in patients with refractory variceal bleeding. Prospective trials comparing this percutaneous procedure and surgical treatment are required.

[Acute intestinal intussusception: ultrasonic diagnosis and air insufflation]. / Invagination intestinale aiguë: diagnostic échographique et réduction pneumatique.

Sixty-five children with intussusception were diagnosed by ultrasonography. Colonic air insufflation was the principle form of treatment. The diagnosis value of ultrasound was 100% and the success rate of reduction by air insufflation was 93%, after intrarectal injection of midazolam (0.3 mg/kg). The device for insufflation was simple, original and manual, with permanent control of intrarectal pressure. No complications were observed.