BackgroundDelays in initiating adjuvant chemotherapy after breast cancer surgery seems to have an impact on patients’ risk of relapse and their survival rate. The aim of this retrospective study was to identify factors delaying initiation of adjuvant chemotherapy after breast surgery.Material and methodsAll patients undergoing surgical treatment for mammary cancer between June 2014 and June 2015 and receiving adjuvant chemotherapy were selected retrospectively.ResultsIn multivariate analysis, 3 factors significantly delay initiation of adjuvant chemotherapy: a secondary procedure (odds ratio [OR], 6.67; P = .00012), inclusion in a therapeutic trial (OR, 8.46; P = .0013), and a positive HER2 status (OR, 3.02; P = .063 [statistically significant]).DiscussionThis study provides a brief overview of the population most likely to experience a delay in the initiation of their adjuvant chemotherapy after cancer surgery. Our findings should assist interventions during initial management.

Il s’agit de présenter la mise en œuvre du repérage des tumeurs mammaires non-palpables par grain d’iode 125 et les résultats intermédiaires d’une comparaison avec la technique classique utilisant un guide métallique (harpon). C’est une étude prospective monocentrique de non-infériorité, randomisée avec une stratification selon le statut histologique. Le repère utilisé est un grain d’iode 125 (IsoSeed® – Eckert & Ziegler) de dimension Ø 0,8 mm×4,5 mm émettant un rayonnement gamma de 27 keV. Le grain d’iode d’activité comprise entre 5 et 10 MBq est mis en place en radiologie sous contrôle échographique ou mammographique jusqu’à 10 jours avant la chirurgie. Le repérage du ganglion sentinelle est réalisé la veille ou le jour même par nanocolloïdes marqués au 99mTc. Des études préliminaires ont permis de vérifier le caractère radio-opaque et échogène du grain ; l’efficacité des sondes peropératoires, notamment en termes de conflit entre le 99mTc et le 125I, la vérification de la présence du grain dans la pièce opératoire (Faxitron), les aspects de radioprotection et le circuit multidisciplinaire du grain. L’étude intermédiaire porte sur les 116 premières patientes. Soixante repérages par harpon et 56 repérages par grain d’iode ont été réalisés. Cinquante grains ont été placés sous échographie et 6 sous mammographie. Les durées de mise en place radiologique et de l’acte opératoire sont réduites avec le grain d’iode (p < 0,03). Le taux de reprise chirurgicale est identique. L’inconfort évalué par échelle EVA est identique lors de la pose du repère et inférieur dans le cas du grain 3 à 24 heures après le geste radiologique (p < 0,003). La présence simultanée de 99mTc et de 125I n’a pas d’influence sur la détection d’un ganglion sentinelle ou d’une lésion repérée par grain. Cette technique multidisciplinaire est faisable. Les résultats intermédiaires sont très encourageants montrant une non-infériorité de la technique du repérage par grain d’iode 125 par rapport au harpon avec un gain en confort pour la patiente et en rapidité pour les opérateurs.

Abstract Introduction : The harvest of the latissimus dorsi muscle for the realization of immediate breast reconstruction induces a large dorsal scar measuring up to 20 centimeters, while only the muscle is used. We present here the results of our experience of endoscopic harvesting of the latissimus dorsi muscle using 3D technology. Our main objective is to reduce the dorsal scar and second assess the functional consequences for patients. Methods: Between December 1st, 2015 , and June 1st, 2016, there were 7 patients who underwent latissimus dorsi endoscopic harvesting, with 3D technology, for an immediate breast reconstruction after a skin-sparing or nipple sparing mastectomy. Results: 4 patients had latissimus dorsi muscle with breast implant and 3 patients by latissimus dorsi muscle only. The age average was 55 years (range 45-70). The mean length of surgery was 250 minutes (range 150- 380). The mean length of hospitalization was 7 days (range 4-12 days). One patient treated for local recurrence had skin necrosis because of previous radiotherapy. Donor site seroma was the main post surgery drawback. Patients on average benefited from 3 evacuations (range 1-5) of 850ml (range 640-1270ml). Acceptance of the reconstructed breast was good in six cases, and poor in one case. Only one patient reported discomfort at the donor site 1 month after surgery. Conclusion: The endoscopic 3D latissimus dorsi flap harvesting allows to reduce donor site scar. There is no significant difference concerning complications or post-operative pain and functional discomfort between the endoscopic and classic harvesting procedure. Citation Format: Barranger E, Dejode M. Endoscopic 3D latissimus dorsi muscle harvesting for immediate breast reconstruction. Results of our 7 patients experience in Antoine Lacassagne Nice Cancer Center [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-14-14.

Background > Patient education is the process by which health professionals impart information to patients and their caregivers that will alter their health behaviors; improve their health status to better manage their lives with a chronic disease. Patient education implies a profound paradigm shift in the conception of care among health professionals, and should result in structural core changes. Patient education has been promoted by the French Health system for 30 years, including in the 2009 HPST law and Cancer Plan 2014-2019. A patient education program was designed in our hospital for breast cancer patients.Material and methods > A multidisciplinary and transversal team of health professionals and resource patients was trained before grant application for funding of the program by the regional health care agency. Management of the project required that a functional unit be built for recording of all patient education related activities. A customized patient education program process was built under the leadership of a coordinator and several patient education project managers during bimonthly meetings, using an accurate timeline and a communication strategy to ensure full institutional support and team engagement.Results > The grant was prepared in four months and the program started within the next four months with the aim to include 120 patients during year 1. The program includes a diagnosis of patient abilities and well-being resources, followed by collective and individual workshops undertaken in 4 months for each patient.Discussion > Patient education is positively evaluated by all participants and may contribute to better health care management in the long term but the financial and human resources allocated to such programs currently underestimate the needs. Sustainability of patient education programs requires that specific tools and more commitment be developed to support health care professionals and to promote patient coping and empowerment in the long term.

Assess the biopsy's feasibility of the sentinel lymph node biopsy (SLNB) using optonuclear probe after of indocyanine green (ICG) and radio-isotope (RI) injections.Twenty-one patients with a localized breast cancer and unsuspicious axillary nodes underwent a SLNB after both injections of ICG and radio-isotope.One or more SLN were identified on the 21 patients (identification rate of 100%). The median number SLN was 2 (1-3). Twenty SLN were both radio-actives and fluorescents (54.1%), 11 fluorescent only (29.7%) and 6 were only radio-actives (16.2%). Seven patients had a metastatic SLN (8 SLN overall). Among them, only one had a micrometastasic SLN, 5 others had a macrometastatic SLN and one patient had two macrometastatic SLNs. Among the 8 metastatic SLN, 5 were both fluorescent and radioactive, 2 were only fluorescent and 1 was only radioactive.Detection SLN using optonuclear probe after indocyanine green and radio-isotope injections is effective and could be, after validation by randomized trial, a reliable alternative to the blue dye injection for teams who consider that combined detection as the reference.

Breast reconstruction is an essential part of breast cancer treatment. After skin sparing mastectomy, Immediate Breast Reconstruction (IBR) can be achieved using breast implants, autologous flaps (i.e. latissimus dorsi-myo-cutaneous flap (LDF)) or an association of both. Robotic assistance has gained popularity in many surgical fields including breast surgery. This study aims to compare the post-operative results of Robotic Assisted Latissimus Dorsi Flap (RALDF) to Traditional Latissimus Dorsi Flap (TLDF) for IBR after Skin Sparing Mastectomy (SSM) without nipple conservation.Between March 2016 and June 2019, all patients who underwent a SSM and a concurrent IBR with a TLDF were retrospectively compared to patients who underwent SSM and a concurrent IBR with a RALDF. Outcomes compared included operative time, length of hospital stay and complications rate.105 cases of SSM with a LDF based IBR were included in the study. 46 patients underwent RALDF and 59 patients underwent TLDF. Mean operative time was longer in the RALDF group (290.5min versus 259.7min). In binary regression, the concomitant placement of breast implant was the only factor associated with an operative time exceeding 290 min (p = 0.032). Univariate analysis showed no significant difference concerning the rate of complications (p = 0.061). After logistic regression, RALDF was associated with a decreased rate of complications (p = 0.042; OR 0.37; IC 95% (0.142–0.966)).SSM with IBR using RALDF is an effective and safe technique. This technique is actually associated with a lower complication rate at the expense of a longer operative time.

L’éducation thérapeutique du patient (ETP) est une démarche visant à aider les patients à acquérir ou maintenir les compétences nécessaires pour gérer au mieux leur vie avec une maladie chronique. En cela, l’ETP implique un changement profond de paradigme dans la conception du soin chez les professionnels de santé. L’ETP est un enjeu dans les politiques de santé successives depuis 30 ans, y compris la loi HPST et le plan Cancer 2014–2019. Un programme d’ETP ambulatoire dans les cancers du sein fut instauré en établissement privé d’intérêt collectif en cours de certification v2014. La formation d’une équipe pluridisciplinaire et transversale constituée de professionnels de santé et patientes ressource a précédé la demande d’autorisation quadriennale et de financement pour pratiquer l’ETP auprès de l’ARS. La gestion du projet a nécessité la création d’une unité fonctionnelle pour traçabilité des actes d’ETP ambulatoire non comptabilisables dans la tarification à l’acte. Sous l’impulsion d’un coordonnateur et de chefs de projets, des réunions de concertation ETP et une stratégie de communication dans l’établissement et des échéanciers (avec rétroplanning) ont permis de réaliser un programme modulaire personnalisé d’ETP pour les patients. Le programme (diagnostic éducatif, 8 ateliers collectifs et 3 individuels, au choix sur 4 mois) a été effectif en 4 mois et l’objectif de plus de 60 patients atteint en 3 mois. Le programme mobilise 0,35 équivalent temps plein médical, et une équipe paramédicale, réunis hebdomadairement par réunion de concertation ETP. Les concepts d’autonormativité, les freins et solutions rencontrés sont développés. L’ETP est perçue très positivement par les patients participants. L’ETP participe à l’attractivité des établissements mais l’incitation financière pour l’ETP est actuellement faible. La pérennisation de l’ETP nécessite de mettre en place des outils spécifiques et de développer une prospective pour favoriser l’engagement des médecins et des patients dans le long terme. Patient education is the process by which health professionals impart information to patients and their caregivers that will alter their health behaviors; improve their health status to better manage their lives with a chronic disease. Patient education implies a profound paradigm shift in the conception of care among health professionals, and should result in structural care changes. Patient education has been promoted by the French Health system for 30 years, including in the 2009 HPST law and Cancer Plan 2014–2019. A patient education program was designed in our hospital for breast cancer patients. A multidisciplinary and transversal team of health professionals and resource patients was trained before grant application for funding of the program by the regional health care agency. Management of the project required that a functional unit be built for recording of all patient education related activities. A customized patient education program process was built under the leadership of a coordinator and several patient education project managers during bimonthly meetings, using an accurate timeline and a communication strategy to ensure full institutional support and team engagement. The grant was prepared in four months and the program started within the next four months with the aim to include 120 patients during year 1. The program includes a diagnosis of patient abilities and well-being resources, followed by collective and individual workshops undertaken in 4 months for each patient. Patient education is positively evaluated by all participants and may contribute to better health care management in the long term but the financial and human resources allocated to such programs currently underestimate the needs. Sustainability of patient education programs requires that specific tools and more commitment be developed to support health care professionals and to promote patient coping and empowerment in the long term.

Le traitement en un jour du cancer du sein se définit par la combinaison au cours du même temps opératoire d’une chirurgie et d’une radiothérapie peropératoire (RIOP) réalisées en ambulatoire. Ce schéma de traitement répond à un des axes du troisième Plan cancer (2014–2019) se définissant par « le développement de la médecine personnalisée ». Pour répondre à l’objectif de contrôle carcinologique, il ne peut être proposé, pour autant, qu’à certaines patientes présentant une tumeur du sein avec des critères cliniques et histologiques bien précis.

Évaluer les résultats à long terme d’un second traitement conservateur radiochirurgical pour une récidive homolatérale d’un cancer du sein. Étude rétrospective monocentrique évaluant les résultats cliniques d’une tumorectomie et une ré-irradiation mammaire partielle accélérée par une technique de curiethérapie interstitielle de bas- ou haut-débit de dose en cas de récidive locale d’une cancer du sein. Pour la curiethérapie de haut débit de dose, les contraintes de dose étaient pour le volume cible anatomoclinique (CTV) : V100 ≥ 95 % (Vx = volume recevant x % de la dose prescrite), V150 < 33 %, V200 < 12 %, DNR (dose-non uniformity ratio) < 0,35. Les données dosimétriques ont été confrontées aux données de toxicité recueillies selon la Common Terminology Criteria for Adverse Events version 4.0. Entre 09/2000 et 09/2014, 117 patientes ont bénéficié d’un second traitement conservateur pour une récidive. Le volume cible anatomoclinique médian était de 50 cm3, les V100, V150 et V200 médians respectivement de 96 %, 38 % et 14 %. Le DNR médian était de 0,43. Après un suivi en médiane de 63 mois (intervalle de confiance à 95 % : 47–75), trois patientes (2 %) ont été atteintes d’une deuxième récidive locale à 70, 82 et 128 mois. Les probabilités de survie sans deuxième récidive locale et de survie sans progression à 5 ans étaient respectivement de 100 % (0–100) et 91 % (85–97). La probabilité de survie globale à 5 ans était de 93 % (87–99). Quatre-vingt-cinq patientes (73 %) ont souffert d’une toxicité, pour 65 % de grade 1, 31 % de grade 2 et 5 % de grade 3. Aucune toxicité de grade 4 ou 5 n’a été constatée. Les fibroses cutanée et sous-cutanée étaient majoritaires (64 %). Les patientes souffrant d’une toxicité sévère (de grade 3 ou plus) avaient un volume cible anatomoclinique moyen statistiquement plus grand (50 contre 73 cm3, p = 0,009). Aucune mastectomie n’a été réalisée pour toxicité induite et la probabilité de survie sans mastectomie à 5 ans était de 99 % (I97–100). En cas de récidive locale de cancer du sein, un second traitement conservateur radiochirurgical peut être proposé en alternative à une mastectomie radicale.

Objectives. - Study of the quality of life of 42 patients who underwent a lipofilling in our institution between 2009 and 2010.Patients and method. - Analysis of cosmetic outcomes, side effects, emotional life and preoperative information received by a cohort of 42 patients contacted by anonymous questionnaires. Comparisons between patients with a single prothesis, latissimus dorsi flap with prothesis, autologous latissimus dorsi flap and rectus abdominal flap.Results. - The response rate was 56% (42 patients). The average volume of fat injected was 80 mL. The aspect of the reconstructed breast and the harmony between two breasts were better after lipofilling (P = 0.0001, P = 0.0005). The evolution of the aesthetic result is satisfying for 64.1% of the patients. In 29% of cases, patients noticed adhesions at the injection site. Apprehension to touch the reconstructed breast and to wear a swimsuit decreases after lipofilling (P = 0.0345;P = 0.0284). All patients declared to be satisfied with the presurgery information. Half of the patients declare that the final result corresponds to their wishes.Discussion. - The side effects of lipofilling were studied from an oncological point of view. Less publications describe the patients quality of life after lipofilling. This surgery improves the breast reconstruction results and helps patients in a social, affective and aesthetic way. Overall, lipofilling improves more consistency in patients reconstructed by single prothesis and improves more appearance in patients reconstructed by single flap.Conclusion. - Lipofilling improves significantly patients' quality of life. A clinical research protocol (GRATSEC) is currently underway to extend its indications. The lipofilling should not replace a bad indication of breast reconstruction. (C) 2013 Published by Elsevier Masson SAS.

Étude de la qualité de vie de 42 patientes ayant bénéficié d’un lipomodelage dans notre institut entre 2009 et 2010.

Le traitement conservateur du cancer du sein (TC) est devenu le traitement chirurgical standard pour les patientes atteintes d’un cancer du sein débutant. Il consiste en une exérèse de la tumeur mammaire associée à une radiothérapie mammaire. Plusieurs essais prospectifs randomisés ont montré l’équivalence en termes de survie globale entre une chirurgie radicale et une chirurgie conservatrice mammaire [1–3]. Le traitement conservateur est caractérisé par l’augmentation du risque de récidive locale homolatérale (RLH). La mise à jour des résultats à 10 ans de l’essai randomisé de l’EORTC met en évidence l’impact de la qualité des berges d’exérèse sur le risque de RLH avec un risque de 17 % en cas de berges microscopiquement saines versus 26,5 % en cas de berges microscopiquement envahies

BACKGROUND:Pure Tubular Carcinoma (PTC) of the breast is a rare histological subtype of invasive breast cancer characterized by a low rate of lymph node involvement. Currently there is no consensus on less surgical axillary node staging according to this histological subtype. METHODS:We performed a retrospective multi-institutional study. Inclusion criteria were PTC, sentinel lymph node detection (SLND) and conservative breast surgery. RESULTS:From January 1999 to December 2006, 234 patients were included in the study from 9 institutions. The median pathological tumor size was 9.59 (1-22) mm. SLN were successfully detected in 98% (229/234) of patients. Among the 234 patients, a macrometastasis was found in 6 cases (2.5%), micrometastasis in 15 cases (6.4%), and isolated cells in 2 cases (0.8%). In the case of patients with SLND macrometastasis, half of them had macrometastasis in the complementary axillary lymphadenectomy, and none in the case of SLN only micrometastasis or isolated cells. Of the 122 patients with a pathological tumor size <10 mm, none had sentinel node macrometastasis. According to a multivariate analysis, pathological tumor size (>10 mm) was the only parameter significatively linked to the risk of lymph node involvement (p = 0.007). CONCLUSION:In a large multi-institutional series with SLND, we have shown that the risk of axillary lymph node involvement in PTC is very low. In the case of PTC <10 mm, we suggest that surgical axillary evaluation, even with SLND, may not be warranted.

Actuellement, la prise en charge chirurgicale du carcinome lobulaire invasif (CLI) pose le problème de la qualité de la chirurgie conservatrice en termes de risque de récidive et de l’application de la technique du ganglion sentinelle.

Clinical evaluation of the nipple-areolar complex is a routine component of the breast screening examination. All persistent unilateral nipple lesion should be viewed with suipicion and Paget's disease of the nipple should be considered. The diagnosis is established by nipple scrape cytology. It is a rare variant of ductal carcinoma in situ. The breast imaging work-up should include a search for an underlying malignancy, present in over 80% of cases, not infrequently multifocal. Preoperative MRI is useful if breast conservative surgery is contemplated because of the high rate of occult malignancy on mammograms and ultrasound. Erosive adenomatosis of the nipple is a benign process that may simulate Paget's disease isolated to the nipple. Less frequently, pagetoid basal cell carcinoma, Bowen's disease and melanoma may be more difficult to differentiate clinically and share the unilateral and chronic features of Paget's disease. Biopsy is needed for diagnosis. Cutaneous extension of a breast cancer is rare but should be suspected in patients with retraction and/or fixed nipple. Eczema is characterized by the bilateral nature of the process, the absence of nipple deformity, the presence of flare-ups and the favorable response to local steroid therapy. (C) 2011 Elsevier Masson SAS and Editions francaises de radiologie. All rights reserved.