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Routine follow-up of breast cancer patients in specialist clinics is standard practice. This follow-up involves regularly scheduled breast cancer check-ups during the disease-free period, in order to detect recurrence. However, demands on specialist resources rise with the increase in the prevalence of diagnosed breast cancer. Since September 2004, it was proposed in our Institut an alternative routine follow-up schedule. Some patients who are in remission for more than 5 years will be deferred to their general practitioner or gynaecologist for follow-up schedule, alternatively with their referent practitioner from the institut (oncologist, radiation oncologist, or surgeon). We herein present the preliminary results of this strategy, and demonstrate that partially transferring primary responsibility for follow-up does not compromise its quality.

Several recent papers have suggested the role of HRT in the development of breast cancers. From the data base of the Institut Curie we compared the clinical characteristics, histoprognosis factors and survival of a cohort of 6737 patients recorded between 1988 and 1999 in which 1482 declared having receive HRT for more than 6 months. Surgical procedure, locoregional recurrence, metastasis, disease free and global survival were compared bet the patient who received an HRT versus the patients who didn't receive this treatment Mammographic diagnosis was more frequent in the HRT group and the age at diagnosis was smaller (p < 10(-4)). Cancers diagnosed in the HRT group were smaller and had a more favourable biologic profile as well as there were more lobular carcinomas and the conservative treatment was more frequent (p < 10(-4)). Mean follow up was 97 months. Recurrence free survival was not different in the two groups but the metastasis free and global survival were better in the HRT group. HRT remained an independent prognostic factor in a multivariate analysis. In western countries the increasing incidence of breast cancer concerns pre as well as post menopausal women. HRT cannot be considered as the only responsible of this augmentation.

The " Standards, Options and Recommendations " (SOR) project, started in 1993, is a collaboration between the Federation of French Cancer Centres (FNCLCC), the 20 French cancer centres, and specialists from French public universities, general hospitals and private clinics. The main objective is the development of clinical practice guidelines to improve the quality of health care and the outcome of cancer patients. The methodology is based on a literature review and critical appraisal by a multidisciplinary group of experts, with feedback from specialists in cancer care delivery. Objectives : To update the Standards, Options and Recommendations clinical practice guidelines for the management of ductal carcinoma in situ of the breast (DCIS). Methods : The working group identified the questions requiring up-dating from the previous guideline. Medline(r) and Embase(r) were searched using specific search strategies from year 1996 to year 2003. In addition several Internet sites were searched in October 2002. Results : Clinical guidelines have been defined for the management of diagnosis, treatment, follow-up, and treatment of recurrence of DCIS. The issue of hormone replacement therapy has also been addressed in the context of DCIS.

Estrogen is the main hormone involved in the development and growth of hormone-dependent breast cancer. Endocrine adjuvant treatment in recent years focused primarily on the use of SERMs, mainly tamoxifen. Tamoxifen actions are complex. It acts by competitive antagonism of estrogen at its receptor site. It has beneficial agonistic effects in preventing bone demineralization in postmenopausal women, but a detrimental agonistic effect by increasing the risk of uterine cancer and of thrombo-embolism. However, the situation is changing rapidly with the introduction of recent aromatase inhibitors, which display high specificity towards aromatase. They suppress plasma estrogen levels in postmenopausal women by inhibiting or inactivating aromatase, the enzyme responsible of the synthesis of estrogens from androgenic substrates. A complete estrogen deprivation in target tissues may eventually induce osteoporosis. Unlike tamoxifen, aromatase inhibitors have no partial agonistic action. During the last 20 years, adjuvant tamoxifen treatment for 5 years was the "gold standard" endocrine treatment in postmenopausal women with hormone-receptor-positive breast cancers. A 25% reduction risk of deaths was observed. Recently, the results of clinical trials comparing aromatase inhibitors to tamoxifen in post menopausal women with hormone-dependent breast cancer showed a benefit in favor of aromatase inhibitors in reducing the risk of recurrence. These trials were either comparative (for anastrozole) or sequential (for anastrozole, letrozole and exemestane). The issues of long term adverse effects (bone) and hormone treatment sequence remain to be addressed.

Since January 2000, sentinel lymph node detection is routinely performed at the Institut Curie, involving a multidisciplinary team of trained surgeons, nuclear medicine physicians, radiologists and pathologists. During a three-year period, 738 patients undergoing tumorectomy with conservative surgical treatment of the breast were included in the sentinel node procedure consisting of systematic pre-operative tumor biopsies, peritumoral lymph tracer injections at tumor contact (radionuclide/blue dye), primary surgical removal of the first sentinel lymph node, frozen section diagnosis, followed by a standardized pathological analysis, and finally the application of precise criteria to determine whether further surgery is necessary. This article is an evaluation of the sentinel lymph node technique in a specialized Center providing a breakdown of the strong points and weak points of the procedure., (Copyright John Libbey Eurotext 2003.)

Breast-conserving treatment for breast cancer combines lumpectomy, axillary nodes treatment and radiotherapy of the breast. Conservative surgery and radiotherapy is now the standard treatment for unifocal, non inflammatory tumors, less than 3 cm in diameter. The widespread use of mammographic screening leads to a significant increase in the proportion of non palpable breast carcinomas, and has contributed to increase the proportion of breast conserving treatments. Neoadjuvant treatments (chemotherapy, radiotherapy and hormonotherapy) can also extend the indications of breast conservation to breast carcinomas larger than 3 cm. Furthermore, in the last ten years, new surgical procedures (sentinel node biopsy, oncoplastic surgery, minimal invasive surgery) have been developed, increasing the surgical possibilities. After a learning phase to establish new standards for these procedures, all these techniques are now part of our standard surgical apparel, thus extending the possibilities of breast conserving surgery.

The HER2 proto-oncogene encodes a transmembrane protein, which is considered to function as a growth factor receptor. Overexpression of this protein found by immunohistochemistry in about 20% of infiltrating breast carcinomas, has a predictive value of response to treatment by trastuzumab, an anti-HER2 humanized monoclonal antibody. Search for HER2 gene amplification is necessary to adapt the immunohistochemical technique quality and also in the cases of delicate analysis or weak overexpression. It is usually carried out by Fluorescence In Situ Hybridization (FISH). A more recent hybridization technique, named CISH because of its chromogenic revelation is an alternative method, which gives highly correlated results with FISH. We present details of this technique, which may be more familiar for the pathologists than FISH, because reading analysis is similar to that of immunohistochemical staining.

As a consequence of increased screening mammography, ductal carcinoma in situ represents a growing percentage of breast cancer diagnoses. The management of per-cutaneous biopsies as well as wire-localized surgical biopsies is a difficult task for pathologists. In this Article, we describe the diagnostic criteria of these lesions as well as the histopathological characteristics of their two principal differential diagnoses: atypical ductal hyperplasia and micro-infiltrating carcinoma. We also detail the utility of immunohistochemistry in the diagnosis of these lesions. This paper reviews the accepted prognostic factors for ductal carcinoma in situ and describes the important techniques needed to characterize them (grade and extent, status of margins and exclusion of microinvasion). Correct handling of pathological specimens, as detailed here, is one of the main keys for therapeutic success with ductal carcinomas in situ. Indeed, if dealt with adequately, such lesions should almost never affect the patient's long-term survival.

The concept of lobular lesions has greatly evolved during the last 30 Years. This disease is still not fully understood and patient management is probably not always optimal. Changes in the histopathological categorization of the lobular changes should help us to better categorize high-risk lesions. The concept of lobular neoplasia conceived as simply a risk factor and not a precursor for subsequent development of invasive carcinoma is a subject of current debate. Molecular biology data and immunoprofiles isolate lobular phenotypes and link them to invasive cancer. Mass screening is challenging the current opinion that lobular disease cannot be detected by mammography. This raises the problem of the optimal management of patients with lobular neoplasia on needle core biopsies.

Margin and histological size of ductal in situ carcinoma or intraductal component of an infiltrative carcinoma are important prognostic factors to predict presence/absence as well as amount of residual tumor burden. Their evaluation requires standardized pathological analysis. These factors should be interpreted in clinical and radiological context.

Introduction: Breast cancer is the most frequent cancer occurring in women. These cancers may rarely develop within ectopic breast tissue. We report a case of ectopic axillary lobular carcinoma presenting as an isolated skin lesion with prolonged evolution., Case-Report: A 62 year-old women had a cutaneous lesion located in her left axilla for the past 4 years. The skin biopsy showed an infiltrating lobular carcinoma. A mammogram and an MRI were as unremarkable as two past mammograms performed since the beginning of the skin lesion. Surgical resection with lymph node dissection, associated with radiotherapy and hormonotherapy with tamoxifen, led to complete remission., Discussion: Ectopic breast tissue is subject to physiological and pathologic changes such as benign or malignant tumours. Cancer occurring in ectopic breast tissue remains rare but this diagnosis must be suspected when confronted with a skin lesion or mass located near the normal breasts.

Context: The "Standards, Options and Recommendations" (SOR) project, started in 1993, is a collaboration between the Federation of french cancer centers (FNCLCC), the 20 french cancer centers, and specialists from french public universities, general hospitals and private clinics. The main objective is the development of clinical practice guidelines to improve the quality of health care and the outcome of cancer patients. The methodology is based on a literature review and critical appraisal by a multidisciplinary group of experts, with feedback from specialists in cancer care delivery., Objectives: To develop clinical practice guidelines for non metastatic breast cancer patients according to the definitions of the Standards, Options and Recommendations project., Methods: Data were identified by searching Medline, web sites, and using the personal reference lists of members of the expert groups. Once the guidelines were defined, the document was submitted for review to 148 independent reviewers., Results: This article presents the chapter radiotherapy resulting from the 2001 update of the version first published in 1996. The modified 2001 version of the standards, options and recommendations takes into account new information published. The main recommendations are: (1) Breast irradiation after conservative surgery significantly decrease the risk of local recurrence (level of evidence A) and the decrease in the risk of local recidive after chest wall irradiation is greater as the number of risk factors for local recurrence increases (level of evidence A). (2) After conservative surgery, a whole breast irradiation should be performed at a minimum dose of 50 Gy in 25 fractions (standard, level of evidence A). (3) A boost in the tumour bed should be performed in women under 50 years, even if the surgical margins are free (standard, level of evidence B). (4) Internal mammary chain irradiation is indicated for internal or central tumours in the absence of axillary lymph node involvement (expert agreement) and in the presence of lymph node involvement (standard, level of evidence B1). (5) Sub- and supra-claviculr lymph node irradiation is indicated in patients with axillary node involvement (standard, level of evidence B1).

Context: The "Standards, Options and Recommendations" (SOR) project, started in 1993 is a collaboration between the Federation of the French Cancer Centres (FNCLCC), the 20 French Cancer Centres and specialists from French Public Universities, General Hospitals and Private Clinics. The main objective is the development of clinical practice guidelines to improve the quality of health care and outcome for cancer patients. The methodology is based on literature review and critical appraisal by a multidisciplinary group of experts, with feedback from specialists in cancer care delivery., Objectives: To develop clinical practice guidelines according to the definitions of the Standards, Options and Recommendations project for difficult diagnoses in surgical pathology or cytopathology in cancer patients., Methods: Data were identified by searching Medline and using the personal reference lists of members of the expert groups. Once the guidelines were defined, the document was submitted for review to 71 independent reviewers., Results: The main recommendations to prevent and reduce the number of difficult diagnoses in surgical pathology or cytopathology are: 1) The development of quality insurance programs with use of written procedures in each pathology laboratory (standard). 2) The knowledge of clinical data in order to explain surgical pathology or cytopathology results (standard). 3) The availability of complementary patient informations (radiologic data . . .) can be useful to explain surgical pathology or cytopathology results (option). The main recommendations to detect lesions associated with difficult diagnosis in surgical pathology or cytopathology are: 1) Tumor types known as potential difficult diagnosis in surgical pathology or cytopathology should be reviewed by a second pathologist. 2) The systematic second reviewing for every case is expensive but has to be done when the difficulty is know (sarcoma, lymphoma . . .) by experienced pathologists. The main recommendations to solve difficult diagnosis in surgical pathology or cytopathology are: 1) Block recuts, use of special techniques (immunocytohistochemistry and molecular biology), additional data from clinicians, second opinion by a local pathologist, or new specimen can be required for establishing the diagnosis (options). 2) Outside second opinion by expert pathologist has to be considered once the other steps did not allow to establish surgical or cytopathology diagnosis (recommendations, expert agreement).