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Aims: The aim of this study was to determine, from a series of cases, the frequency and prognostic factors of invasion of non-sentinel lymph nodes when the axillary sentinel lymph node contains a metastasis < or =2 mm, and thereby select a population in which completion axillary dissection could be omitted., Methods: Between July 1996 and July 2003, 62 patients, which axillary sentinel lymph node contained a metastasis < or =2 mm had an evaluation of the axillary non-sentinel lymph nodes. Eleven patients had also an evaluation of internal mammary lymph nodes., Results: Eleven patients had axillary non-sentinel lymph node invasion: six by metastases < or =2 mm and five by macrometastases. When internal mammary lymph nodes were also concerned, nodal invasion apart from the axillary sentinel lymph node was seen in 14 patients. Vascular lymphatic invasion was the only factor, statistically significant, linked to non-sentinel lymph node invasion (p = 0.02)., Conclusion: Whatever the size or method of histological detection (pN1mi or pN0(i+)), the presence of a metastasis < or =2 mm in the axillary sentinel lymph node leads us to carry out completion axillary dissection to optimize staging and loco-regional control of the disease.

Background: The primary management of adult soft tissue sarcomas (STS) is characterized by heterogeneity across centers. Several studies suggest that it is improved when coordinated by specialized sarcoma centers., Patients and Methods: This study, comparing STS patients of the Rhône-Alpes region treated within and outside the cancer network, retrospectively assesses the conformity of medical practice with 'evidence-based medicine' (EBM) reported under the clinical practice guidelines (CPGs) of the French Federation of Cancer Centers. Institutional records of 100 new STS patients seen between 1999 and 2001 in the regional comprehensive cancer center and Lyon University hospital were analyzed retrospectively (50/300 new files randomly selected in each institution). Medical decisions were checked for conformity with CPGs., Results: Median age was 58 years (range 18-88) and median tumor size was 9 cm (range 1-26). The most common primary sites were extremities, viscera or trunk. The most frequent histology was leiomyosarcoma (21%) or liposarcoma (12%). Only 7% of cases were reviewed by formal multidisciplinary committee before biopsy (with 42% pre-surgery biopsies only). The first surgical resection was R0, R1 and R2 in 26, 29 and 45% of cases, respectively. Conformity to CPGs was rated 52, 81, 94 and 95% for initial surgery, radiation therapy, chemotherapy and follow-up, respectively. At multivariate analysis, pre-surgery multidisciplinary discussion, management in reference center and management within cancer network independently predicted conformity to CPGs., Conclusions: Conformity with EBM was similar to previous reports. Elaboration of treatment strategy within a formal multidisciplinary staff and treatment within a cancer network are both important prognostic factors for optimal clinical care.

Thirty-five patients with clinically N0 cancers of the canal anal, 33 epidermoid carcinomas et 2 melanomas were histologically staged with inguinal sentinel lymph node biopsy (ISN). With the combined technique, blue dye and radiocolloid the ISN was identified in 100% of the cases. The ISN was invaded in 7 cases/33 for epidermoid tumors and 2/2 for melanomas. After 18 months of follow-up, no inguinal recurrence could be seen in ISN pN0 cases. In conclusion, ISN biopsy is a reliable procedure to stage anal canal cancers. It should prevent unnecessary prophylactic inguinal irradiation for pN0 ISN. Inguinal irradiation is only indicated in pN1 ISN.

Aims: To report outcomes of adults with retroperitoneal sarcoma (RS) treated by surgery, external beam radiotherapy (EBRT) and intraoperative electron beam radiotherapy (IORT)., Methods: From July 1988 to February 2001; 24 patients with primary and recurrent RS were diagnosed and treated. The median dose and energy of IORT delivered was 15 Gy/9meV. EBRT dose varies between 45-50 Gy., Results: There were five primary and 19 recurrent tumours. One primary and five recurrent tumours underwent R0 resection. There were 12 liposarcomas and 19 grade I tumours; 13 patients developed local recurrence and three developed distant metastases.Twenty-two patients received IORT associated with EBRT: 11 developed recurrences. Six patients developed Neurotoxicity (4 grade II and 2 grade III). Disease free survival and overall survival at 5 years was 28 and 56% respectively., Conclusions: EBRT with IORT treatment is a promising technique for local control. Lower recurrence rates are associated with radical (R0) surgical procedures.

Cancer is still considered from a physiopathological point of view as a disease of the cell. This concept is underlying the idea of cure. Treatment with curative intent should aim at eradicating all the tumoral cells. Local control is mandatory and essential in cancers localized in organ with vital function. In breast cancer a complex and controversial relationship exists between local relapse and increased risk of fatal distant metastasis. In case of organ preserving treatment, a complete local control is necessary from the start. If a too high risk of local relapse is foreseable, conservative treatment should not be recommended.

Radio-induced angiosarcoma of the breast after conservative therapy for invasive adenocarcinoma is a very rare tumour. Between 1996 and 2000, four cases were operated in our Department of Surgical Oncology. After a review of the literature over the same period of time, natural history and treatment of radio-induced angiosarcomas of the breast were analysed., (Copyright Harcourt Publishers Limited.)

Induction chemotherapy (IC) provides in more than 20% of cases a complete shrinkage of the tumor. This down staging is a new challenge for the surgeons for breast conservative procedure. Although, IC has become the standard of care for breast cancer T2 > 3 cm T3 N0 N1 M0. No guidelines have devoted attention to the surgical problems due to this down staging after IC. Location and size of the tumor before IC have to be studied and outlined by the surgeon himself. During surgery, the residual tumor volume and how much mammary gland must be removed are very difficult to determine. The maximum volume of mammary gland to be removed after IC around the primary site of the tumor before IC is the volume which permits a good cosmetic reconstruction of the breast. After IC, in spite of an important downstaging, an axillary clearance must be done. For N0 patients, sentinel lymph node biopsy could be performed before IC. If the sentinel node is p N0, axillary clearance could be avoided.

Background: The sentinel lymph node (SLN) procedure has been proposed to women with breast cancer with clinically negative axillary lymph nodes, in order to avoid conventional axillary lymph node dissection and its associated side-effects. Methodological aspects of the validation of the SLN procedure are questioned here., Materials and Methods: The results of relevant published studies are reviewed, with emphasis on pathological techniques. The ability of the SLN procedure to diagnose lymph node metastases, the extent to which axillary lymph node dissection contributes to treatment, apart from identification of the stage, and the effect of a modified staging procedure on treatment strategies are analyzed., Results and Conclusion: Both the sensitivity and the negative predictive value of the SLN procedure are overestimated if the probability of missing lymph node metastases is not taken into account, even when a complete axillary dissection is performed as a control. The SLN strategy and its effects on staging and treatment cannot be evaluated by comparison with conventional axillary lymph node dissection in a one-arm study but require carefully designed randomized trials.

Abdominal wall metastasis to laparoscopic trochar sites after preoperative staging procedure is rare for uterine cervix cancer. Prognosis is unfavorable. We report a case of metastasis to a laparoscopic trochar site in a patient with a stage IIB cervical cancer with no nodal involvement who is alive four and a half years after radical surgery and radiotherapy.

A long-term retrospective study of breast reconstruction with inflatable implants is presented. One hundred and one patients were studied, with a median follow-up of 44 months. Prosthetic implants used were round McGhan implants, model 168. Median volume was 215 mL. Twenty-two patients had contralateral symmetrisation, an average of five months after implant. The advantages of this sort of reconstruction are ease, speed and homogenously good results. Drawbacks include the appearance of prosthetic leaks (7%), waves and folds (13%), stage III and IV capsular contractures (26%), asymmetry and incorrect placement of the implant (25%). Breast reconstruction with implants alone gives good results for specific indications: immediate reconstructions, bilateral reconstructions, no history of radiotherapy, and good quality chest wall tissues.

The majority of patients with breast cancer can be treated by partial mastectomy and radiation therapy. The choice of the treatment involves the estimation of the risk for intramammary recurrence and the ability to achieve satisfactory cosmetic result. Patient selection in breast conserving therapy is dependent on clinical and histologic characteristics of the tumor, but many times the therapeutic decision is not easy. We present a review of the literature in order to try to resolve some controversed questions about breast conservation in relation to tumor size, margin status, tumor location, multicentricity, histologic subtype or presence of extensive intraductal component, age of patients and genetic factors.

Intra Operative Radiation Therapy (IORT) has been routinely used for the past 20 years. It is a feasible treatment, with a reasonable cost and an acceptable acute and late toxicity. There is so far no strong randomized trial demonstrating that IORT can improve overall survival. Nevertheless, in many institutions it is recognized as an efficient treatment in selected patients. In case of locally recurrent disease an incomplete gross resection is often the only choice; IORT in such a situation has led to very encouraging results. For locally advanced deep seated primary tumors IORT seems to improve local control. In the near future IORT should be used on a larger and stronger basis. The manufacturing of new mobile linac should allow more surgeons to perform IORT and to conduct clinical trials to confirm the present indications in cancers with high local malignancy.

Tamoxifen is widely used nowadays in the management of breast cancer, having established its efficacy in this indication, especially for postmenopausal patients with ER-positive breast tumours. However, tamoxifen has recently been recognized as carcinogenic for the human endometrium, probably with an effect of duration of treatment. Moreover, this drug may be associated with the occurrence of endometrial cancers of unusual histological types and/or of a more aggressive nature. We describe a case series of 11 patients who developed such cancers after having previously received tamoxifen for breast cancer. Several assumptions on the mechanisms underlying the attributed carcinogenic properties of tamoxifen, for the endometrium and potentially for other organs, are discussed on the basis of current knowledge.

Surgical oncology requires an indispensable cultural and interdisciplinary approach of cancer. It needs a solid surgical formation combined with knowledges in biology, pathology, radiology, chemotherapy, and radiotherapy so oncologist surgeons are better able to define the limits of intervention according to the natural history of each type of tumors and the last modern therapeutic means.

Post-coitus vagina-bladder fistulas are rarely encountered although they may be favoured by radiosurgical treatment for cervical cancer. Treatment is particularly difficult. When initial epiploplasty is a failure, most authors recommend an ileocytoplasty with ad integrum reconstruction of the vaginal and of bladder function.

The role of local control in the cure of solid tumors remains a matter of crucial importance particularly for the cases of conservative therapy. Arguments that higher local control rates would result in more cured patients is a subject of controversies for some tumors as breast cancer. For tumors with different natural history, the authors outlined the crucial role of local control to improve cure rate thank to surgery and radiotherapy.

Full thickness chest wall reconstruction must restore a leak-free and semirigid chest wall that allows good respiratory function. We present five consecutive cases of chest wall reconstruction with skeletal frame reconstruction by an osteomusculocutaneous latissimus dorsi flap. This flap allows transfer of the 11th and 12th ribs. The chest wall resection was performed for chest wall sarcomas (four cases) and radionecrosis (one case). The functional results are good. The bone scan showed the good vitality of the transferred ribs. This flap has the advantages of an autologous vascularized bone transfer. It is a useful flap for large full thickness chest wall reconstructions that need a skeletal frame reconstruction.

The reconstruction of major inferior abdominal wall defects is a rare but difficult problem. We present five consecutive cases of reconstruction following major excision for the treatment of tumors (3 cases) and radionecrosis (2 cases). The immediate reconstruction was performed by fasciomyocutaneous flaps of the thigh, pedicled on the tensor fascia lata (4 cases) or the rectus femoris (1 case). The functional results of the abdominal reconstruction are good. The sequelae of the donor site are mainly aesthetic; the function of the thigh is not affected by the harvest. These two flaps are very reliable. The rectus femoris flap has muscle throughout the extent of the flap and may be preferred in contaminated wounds or postradiation ulcers. It also allows the midline to be reached more easily.

Thirty-seven ovarian cancer-prone families have been identified through a French co-operative network. Three main clinical presentations were observed: site-specific ovarian cancer, breast/ovarian carcinoma syndrome and Lynch syndrome II. An additional kindred with features of Li-Fraumeni syndrome is reported. It is expected that a better understanding of the mechanisms of carcinogenesis will allow the development of new methods of screening and treatment. With this aim, recent studies have mapped the gene for early-onset familial breast cancer and breast/ovarian carcinoma syndrome to the same locus in the chromosome 17q12-q23 region. Results from linkage analysis of two breast/ovarian carcinoma families and three breast cancer families favour the hypothesis of genetic heterogeneity among breast and ovarian tumors.

Adenosarcoma is a rare tumour of the uterus which contains normal benign epithelial cells together with sarcomatous over-growth of the stroma. The tumour is an intracavitary one which gives rise to bleeding but has a relatively favourable prognosis because it has a low degree of malignancy.

Plastic surgery has acquired an important place in primary breast cancer treatment (conservative or radical) and in the treatment of sequelae. The authors have tried to define, based on their experience, the contraindications for breast reconstruction. They are rare from a technical point of view. The carcinologic contraindications are relative: highly aggressive cancers, locally advanced cancers, cancers with metastases or recurrences. Radionecrosis and radio-induced sarcomas, treatment sequelae are also contraindications for breast reconstruction. General contraindications are relative (major obesity, smoking, diabetes, general weakness). Psychological contraindications must be taken into consideration. The authors conclude that contraindications for breast reconstruction are mainly carcinologic and the decision for reconstruction is usually taken by the patient after complete medical information.

Twenty cases of endometrial carcinoma are reported, observed in women who had received long term tamoxifen treatment as adjuvant therapy for breast cancer. Furthermore, a specific study was carried out on an homogeneous group of 790 women with an operable breast cancer, 318 receiving tamoxifen as adjuvant treatment. Five endometrium carcinoma were observed in the group under tamoxifen versus none in the other group. From an analysis of these cases, authors will carry out a case control study to evaluate the relative risk of endometrial carcinoma for patients under tamoxifen. They underline the importance of gynecologic follow up procedures for all women receiving this endocrine therapy.

The case of a forty-three year old woman is reported. She was operated on for a pelvic abdominal multicystic peritoneal mesothelioma which was discovered at the time of a systematic gynaecological examination. We specify the anatomo-clinical characteristics of multicystic mesothelioma from the 118 cases described in the literature and related in detail the stages of histopathological diagnosis. We question the differential diagnosis with serious ovarian tumours.

A case is reported of oesophageal perforation which occurred during an attempt to carry out endotracheal intubation. A 54-year-old female patient was scheduled for mastectomy. She had no clinical features likely to predict a difficult endotracheal intubation. After induction with thiopentone, phenoperidine and suxamethonium, three attempts were made to carry out tracheal intubation with a Mallinckrodt Lo-pro tube, internal diameter 7.5 mm. During the third attempt, the oesophagus was accidentally intubated. The diagnosis was made before any insufflation was carried out. Another anaesthetist took over, and intubated the patient. At that time, there was left-sided cervical emphysema which quickly spread. An oesophageal perforation was suspected, and the patient was given 500 mg of metronidazole and 1 g of cefotetan. Postoperatively, the antibiotics were continued, and the patient had nothing by mouth. Oesophagography showed a posterior fistula in the upper third. Conservative treatment was continued until the seventh day, when another oesophagography was carried out. This showed that the perforation had completely healed. This rather rare complication of endotracheal intubation may have a poor prognosis if it results in mediastinitis. The diagnosis and prognosis of this complication and its treatment, whether conservative or surgical, are discussed.

The present study is based on the data of a homogeneous series of 736 women with stage I and II operable breast cancer. The same methodology was used for treatment and follow-up. Eighty-seven patients were under 40 and 649 between 40 and 70 years ols. No statistical difference was noted between the distribution in these 2 groups regarding tumor size, the axillary or internal mammary nodal status or hormonal receptor levels. Small tumors were noted more frequently in the under 40 yr group. Overall survival was the same in both groups, independently of tumor size, axillary nodal status or hormonal receptors. Disease-free survival differed between the 2 groups: local relapse risk was 1.6 times higher for women under 40 yr, in relation to a higher frequency of conservative treatment in this group. No difference was noted for DFS in relation a tumor size, axillary nodal status of hormonal receptors.

Short term preoperative irradiation of rectal cancer (30 Gy in 12 days) followed by a two-month rest before surgery has proven to be more efficient than most usual protocols of radiotherapy. In a series of 136 tumors T2, T3 or T4, tumor-free specimens and Duke'A lesions were found at surgery in 17% and 36% respectively. Surgeons took advantage of the tumor regression and performed sphincter-saving surgery in 41 patients with T2, T3 or T4 tumors of the lower third of the rectum. Of 30 patients followed from 2 to 6 years, the disease-free survival rate is 86%. Only one local failure was observed and subsequently controlled by abdomino-perineal resection.

Based on our experience with 12 patients who underwent wide anterior chest wall resection in our institute, we attempt to define the indication of the different techniques for reconstruction by musculo-cutaneous flaps according to the extent of resection and location in the chest wall. The pectoralis major flaps are simple and important in the reconstruction of sternal defects; especially when dense retrosternal fibrosis has already developed after radiotherapy. The latissimus dorsi flaps are reliable and thick and suitable for coverage of major tissue loss. A new technique is also described for reconstruction of major anterolateral chest wall defects as well as sternal defects by a latissimus dorsi osteo-muscular flap. The external oblique musculo-cutaneous flaps are used to cover defects in the lateral chest wall below the 5th rib. Pedicled omental flaps are complementary flaps and can be used when muscle flaps are insufficient to replace significant tissue loss. Respiratory problems arising from paradoxical chest wall movement are temporary and may be encountered in the immediate post-operative period. Because of the development of fibrosis and of a better adaptation of the patient, this condition is well tolerated during the month following operation.

A case is reported of bacterial meningitis related to an intradural implant used in the treatment of pain into which morphine was administered daily. The infection began on the third day after implantation of the system. Because of its efficiency in controlling pain, it was not removed; the infection was successfully treated with local and general antibiotic treatments only. The system was used 121 days.

From 1953 to 1972, 149 patients at Centre Leon Bérard, were treated by pelvic exenteration for carcinoma of the cervix. A review of the literature and of our cases showed that the mortality rate varied between 12 and 38 per cent according to the authors. In our experience, the final cause of death has been essentially pelvic reccurences within 18 months of the operation. For Ketcham, the patients died principally from metastases. To illustrate these results, criteria for patient selection for pelvic exenteration are outlined, with some suggestions for operative and post-operative management. The pre-operative medical status, the roentgenographic studies and finally exploratory laparotomy eliminated all but a very small number of patients, 15 to 20 per cent. Pelvic exenteration is appreciably beneficial only for this small group. Indeed, the exenteration is acceptable only when it does not result in excessive mutilation disproportinate with the chances of survival. It is conceivable only as curative treatment requiring a radical loco-regional excision, not only for the involved viscerae but also for the pelvic lymph nodes.

Conservative treatment of rectal cancer by intracavitary irradiation (Philips contact x-ray therapy followed or not by Iridium implant) is only applicable to tumours which are thought to have no lymphatic spread. A strict selection of cases is compulsory, especially with regard to the probability of lymph node involvement (degree of histological differentiation, degree of infiltration of the rectal wall, absence of palpable pararectal metastatic lymph nodes). After treatment, follow-up must be performed methodically. Moreover, in patients not older than 55, mesenteric and perirectal lymphadenectomy must be considered. At the Centre Léon Bérard (Lyon), 231 patients followed more than 5 years have been treated. The 5-year and 10-year survival rates are respectively 57 per cent and 74 per cent. The rate of local failure is 5.2 per cent. The rate of death from cancer at 5 and 10 years is 10 per cent. However intracavitary irradiation is only applicable in 10 to 15 per cent of rectal cancers. A new conservative approach has been worked out. It consists of preoperative external beam irradiation with Cobalt 60 (30 Gy in 12 days) followed 2 months later, according to the residual disease, either by radical surgery of Iridium implant. Applied to poor risk, patients this method can spare many of a permanent colostomy, without jeopardizing their chances of cure (27 cases, median age: 77 years).