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Gilles Houvenaeghel,1 Eric Lambaudie,1 Marie Bannier,2 Sandrine Rua,2 Julien Barrou,2 Mellie Heinemann,1 Max Buttarelli,2 Jeanne Thomassin Piana,3 Monique Cohen2 1Department of Surgical Oncology, Paoli Calmettes Institute and CRCM, CNRS, INSERM, Aix Marseille Université, 13009 Marseille, France; 2Department of Surgical Oncology, Paoli Calmettes Institute, 13009 Marseille, France; 3Department of Pathology, Paoli Calmettes Institute and CRCM, CNRS, INSERM, 13009 Marseille, France Introduction: Reoperation after breast-conserving surgery (BCS) could be proposed for positive or close margins. Reoperation type, re-excision or mastectomy, depends on several factors in relation to patient’s and tumor’s characteristics. We have analyzed our breast cancer (BC) database in order to determine second and third attempts for BCS and mastectomy rates, as well as associated factors for type of surgery. Methods: All patients with BCS between 1995 and 2017 were included. Patient’s characteristics, pathologic results, and treatments were analyzed. Reoperation rate, type of reoperation, second reoperation, and associated factors of reoperation, mastectomy, and third intervention were determined. Three periods were determined: P1–P3. Results: We analyzed 10,761 patients: 1,161 with ductal carcinoma in situ (DCIS) and 9,600 with invasive BC. The reoperation rate was 41.4% for DCIS and 28.0% for invasive BC. Using multivariate analysis, we identified tumor size >20 mm as being a risk factor for reoperation, whereas age >50 years, P2–3, and some localization decreased reoperation rates. For invasive BC, age >40 years, triple-negative tumors, neoadjuvant chemotherapy, and noncentral tumors decreased reoperation rates and lobular tumor, multifocal tumors, lymphovascular invasion, DCIS component, and Her2-positive tumors increased reoperation rates. For patients requiring reoperation, re-excision was performed in 48.1% (1,523/3,168) and mastectomy was required after first re-excision in 13.46% (205/1,523). For DCIS, mastectomy rates were higher for grade 2 and tumor ≥20 mm. For invasive BC, mastectomy rates were higher for lobular, multifocal, ≥20 mm, Her2-positive tumors and diffuse positive margins and lower for age >50 years and during the last period. Even if interval time between surgery and adjuvant treatments was higher for patients with reoperation, survival rates were not different between patients with and without reoperation. Conclusion: A decrease in reoperation and mastectomy rates had been reported with several associated factors. A third intervention with mastectomy was required in 13.5% of patients. This information should be done in case of reoperation. Keywords: breast cancer, conservative surgery, mastectomy, reoperation, margins

Background: Pelvic exenteration remains one of the most mutilating procedures, with important postoperative morbidity, an altered body image, and long-term physical and psychosocial concerns. This study aimed to assess quality of life (QOL) during the first year after pelvic exenteration for gynecologic malignancy performed with curative intent. Methods: A French multicentric prospective study was performed by including patients who underwent pelvic exenteration. Quality of life by measurement of functional and symptom scales was assessed using the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30 (version 3.0) and the EORTC QLQ-OV28 questionnaires before surgery, at baseline, and 1, 3, 6, and 12 months after the procedure. Results: The study enrolled 97 patients. Quality of life including physical, personal, fatigue, and anorexia reported in the QLQ-C30 was significantly reduced 1 month postoperatively and improved at least to baseline level 1 year after the procedure. Body image also was significantly reduced 1 month postoperatively. Global health, emotional, dyspnea, and anorexia items were significantly improved 1 year after surgery compared with baseline values. Unlike younger patients, elderly patients did not regain physical and social activities after pelvic exenteration. Conclusions: Therapeutic decision on performing a pelvic exenteration can have a severe and permanent impact on all aspects of patients' QOL. Deterioration of QOL was most significant during the first 3 months after surgery. Elderly patients were the only group of patients with permanent decreased physical and social function. Preoperative evaluation and postoperative follow-up evaluation should include health-related QOL instruments, counseling by a multidisciplinary team to cover all aspects concerning stoma care, sexual function, and long-term concerns after surgery. [ABSTRACT FROM AUTHOR]

Aims To compare survival outcomes after mastectomy (Mt) and lumpectomy plus interstitial brachytherapy (LpIB) in the treatment of breast cancer local recurrence (LR) occurring after conservative surgery. Methods Medical records of patients treated for an isolated LR from January 1, 1981 to December 31, 2009 were reviewed. To overcome the bias due to the fact that treatment choice (Mt or LpIB) was based on prognostic factors with LpIB proposed preferentially to women with good prognosis, Mt and LpIB populations were matched and compared with regard to overall survival (OS) and metastasis free survival (MFS). Results Among 348 patients analyzed, 66.7% underwent Mt, 17.8% LpIB and 15.5% Lp alone. After a median follow-up of 73.3 months, 65 patients had died (42/232 Mt, 8/62 LpIB, 15/54 Lp). Before matching, OS and MFS at 5 years were significantly better in the LpIB compared to the Mt group, due to significantly more frequent poor prognostic factors in the latter (p = 0,07 and p = 0,09 respectively, log-rank significance limit of 10%). After matching, the benefits of LpIB disappeared since MFS and OS rates were not significantly different in both groups (p = 0.68 and 0.88 respectively). After LpIB, the second LR rate was 17% at 5 years and 30% at 10 years. Conclusion A second conservative breast cancer treatment associating lumpectomy and interstitial brachytherapy is possible for selected patients with LR, without decrease in neither OS nor MFS compared to mastectomy. [ABSTRACT FROM AUTHOR]

Objective This study aims to evaluate the different surgical approaches, perioperative morbidity and surgical staging according to age in patients with endometrial cancer. Methods Multicentre retrospective study. Cancer characteristics and perioperative data were collected for patients surgically treated for endometrial cancer. The patients were divided into 2 groups according to their age: younger or older than 75 years. Results Surgery was performed on 270 women <75 years old and on 74 ≥ 75 years old. Minimally invasive surgery was performed less often in the elderly compared with their younger counterparts (58.2% vs. 74.8%; p = 0.006). Independently of the surgical approach, the rate of pelvic and para-aortic lymphadenectomy was lower in women older than 75 years old than their younger counterparts (52.7% vs. 74.8%; p < 0.001; 8.1% vs. 21.8%; p = 0.007 respectively). According to the guidelines, more frequent surgical understaging was seen in the elderly compared with the younger (37% vs. 15.2%; p = 0.002). In the comparison of complications for each surgical approach, there was no statistical difference in the ≥75-year-old age group in terms of intra- or postoperative complications between the laparotomy, laparoscopy or robotic surgery group. We found a shorter length of hospital stay for the women who underwent laparoscopy or robotic surgery compared with laparotomy (p < 0.0001). Conclusion Elderly women with endometrial cancer are often surgically understaged whereas there is no evidence of greater perioperative complications than for their younger counterparts. They should benefit from minimally invasive surgery and optimal surgical staging to the same extent as younger women. [ABSTRACT FROM AUTHOR]

Background: Triple-negative breast cancers (TNBCs) are the most deadly form of breast cancer (BC) subtypes. Axillary lymph node involvement (ALNI) has been described to be prognostic in BC taken as a whole, but its prognostic value in each subtype is unclear. We explored the prognostic impact of ALNI and especially of small size axillary metastases in early TNBCs.Methods: We analysed in this multicentre study all patients treated for early TNBC in 12 French cancer centres. We explored the correlation between clinicopathological data and ALNI, with a specific focus on the dichotomisation between macrometastases and occult metastases, which is defined as the presence of isolated tumour cells or micrometastases. The prognostic value of ALNI both in terms of disease-free survival (DFS) and overall survival (OS) was also explored.Results: We included 1237 TNBC patients. Five-year DFS and OS were 83.7% and 88.5%, respectively. The identified independent prognostic features for DFS were tumour size >20 mm (hazard ratio (HR)=1.86; 95% CI: 1.11-3.10, P=0.018), lymphovascular invasion (HR=1.69; 95% CI: 1.21-2.34, P=0.002) and ALNI both in case of macrometastases (HR=1.97; 95% CI: 1.38-2.81, P<0.0001) and occult metastases (HR=1.72; 95% CI: 1.1-2.71, P=0.019). DFS and OS were similar between tumours with occult metastases and macrometastases. Tumours presenting at least two pejorative features (out of ALNI, lymphovascular invasion and large tumour size) displayed a significantly poorer DFS in both the training set and validation set, independently of chemotherapy administration. Tumours with no more than one of the above-cited pejorative features had a 5-year OS of ⩾90% vs 70% for other cases (P<0.0001).Conclusions: Axillary lymph node involvement is a key prognostic feature for early TNBC when isolated tumour cells were identified in lymph nodes. This impact is independent of chemotherapy use. [ABSTRACT FROM AUTHOR]

Background Two options are possible for the management of early stage cervical cancer, without lymph node involvement: radical surgery or brachytherapy followed by surgery. The aim of this study was to compare overall survival (OS) and disease-free survival (DFS) of early stage cervical cancers managed by uterovaginale brachytherapy followed by extrafasciale hysterectomy (group 1) or by radical hysterectomy alone (group 2). The secondary objectives were to compare the morbidity of these two different approaches and to evaluate the parametrial involvement rate in patients managed by radical hysterectomy. Materials and methods It is a retrospective and collaborative study between the Paoli Calmettes Institute (Marseille) and the Oscar Lambret Center (Lille) from 2001 to 2013, in patients with tumors FIGO stages IA1, IA2, IB1 and IIA less than 2 cm of diameter, without pelvic lymph node involvement. Results One hundred and fifty-one patients were included (74 in group 1 and 77 in group 2). The demographic characteristics of the two groups were comparable. OS and DFS were respectively 92.3% versus 100% (p = 0.046) and 92.3% and 98.7% (p = 0.18). Complication rates were 12.2% and 44.2%, respectively (p < 0.0001). In group 2, the parametrial invasion rate in this study was 1.30%. Conclusion In our study, the two strategies are comparable in terms of DFS. Complications seem more frequent in the group 2, but more severe in the group 1. Finally, the low rate of parametrial invasion in group 2 confirms the interest of a less radical surgical treatment in these stages with good prognosis. [ABSTRACT FROM AUTHOR]

In the field of gynaecological and senological oncological surgery, admission to the outpatient department is particularly developed. For breast surgery, this development was made possible through an appropriate structure that takes into account the special requirements and the pre-, intra- and post-operative stages. At the same time, outpatient surgery for gynaecological oncological pelvic procedures is beginning to be developed, however it is more limited. We are proposing: 1) definitions of outpatient care; 2) the specific structure, as well as how this will be facilitated, including financial means; 3) the contribution of minimally invasive techniques; 4) current and future indications. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: The aim of this study is to establish the feasibility of the management of recurrent pelvic cancers by robot-assisted laparoscopy, and particularly the feasibility of robot-assisted laparoscopy anterior pelvic exenteration, from a single center series of seven patients. Patients and methods: From February 2007 to April 2010, all patients cared for recurrent pelvic cancer have been included (n =7). Five patients have been cared for a cervical cancer recurrence, one patient for recurrent VAIN 3, and one patient for squamous cell carcinoma of the vaginal vault after hysterectomy for cervical carcinoma in situ. All patients were benefited from robot-assisted laparoscopy: two had surgery such as anterior pelvic exenteration with Miami Pouch urinary reconstruction, and five had colpectomy with or without lymph node removal, including one with vaginal preparation first before vaginal cuff resection. Data were collected prospectively identifying treatment history, intraoperative data, immediate outcomes, pathological findings, and long-term outcomes. Results: From February 2007 to April 2010, 195 patients underwent robot-assisted laparoscopy at the Institut Paoli-Calmettes. Among them, seven patients had pelvic cancer recurrence. The median age was 53 years (44 to 67). The median BMI was 25 (19.7 to 35.3). The median Karnofsky index was 100 (80–100). The median operative time was 210min (90 to 300) for colpectomy, 480 min for pelvectomy, 240min (90–480) for the serie. The mean duration of the installation of the robot, all procedures combined, is estimated at 22.5 min (±4.8min). There was no conversion to laparotomy, the median blood loss was 340ml (100 to 800). One patient was transfused with two red blood cells. There was a surgical complication (wound of the inferior mesenteric artery). There were no early postoperative complications and the median hospital stay was 6 days (3–24). There was a late postoperative complication: a patient who underwent anterior pelvic exenteration had impaired wound healing, with scarring requiring led by the VAC system. On pathological findings, the average number of nodes removed in the pelvic was 8.5 (±2) on the left, and 4 (±1.4) on the right. Three patients had involved margins; it was an anterior pelvic exenteration and two colpectomy. There was no hospital mortality, neither post-operative mortality at D30 and D90. After a median follow up of 22 months (9–34), the recurrence rate was 71% (5 patients out of 7), and one patient died 10 months after the intervention of a pulmonary embolism. Discussion and conclusion: The surgical management of recurrent cervical cancer by laparoscopy-assisted robot is feasible for selected indications, and could be proposed as an alternative to laparotomy. Monitoring data in this series raise the question of the validity of conservative treatment in cases of recurrent pelvic cancer. The possibilities in terms of urinary and vaginal reconstruction remain to be defined. The impact of this surgical approach on oncological data must be confirmed. [Copyright &y& Elsevier]

Background: Prognosis of ovarian carcinoma is poor, heterogeneous, and not accurately predicted by histoclinical features. We analysed gene expression profiles of ovarian carcinomas to identify a multigene expression model associated with survival after platinum-based therapy.Methods: Data from 401 ovarian carcinoma samples were analysed. The learning set included 35 cases profiled using whole-genome DNA chips. The validation set included 366 cases from five independent public data sets.Results: Whole-genome unsupervised analysis could not distinguish poor from good prognosis samples. By supervised analysis, we built a seven-gene optimal prognostic model (OPM) out of 94 genes identified as associated with progression-free survival. Using the OPM, we could classify patients in two groups with different overall survival (OS) not only in the learning set, but also in the validation set. Five-year OS was 57 and 27% for the predicted 'Favourable' and 'Unfavourable' classes, respectively. In multivariate analysis, the OPM outperformed the individual current prognostic factors, both in the learning and the validation sets, and added independent prognostic information.Conclusion: We defined a seven-gene model associated with outcome in 401 ovarian carcinomas. Prospective studies are warranted to confirm its prognostic value, and explore its potential ability for better tailoring systemic therapies in advanced-stage tumours. [ABSTRACT FROM AUTHOR]

The laparoscopic approach, over the past 20 years, has become, in Gyn Oncologic Surgery, a gold standard for several teams. Introduced 10 years ago, robot-assisted laparoscopy is increasingly used in the gynecologic surgical field. For the surgeon, the advantages of this intuitive robotic surgery are the three-dimensional approach, the precision of the dissection with robotic instrument articulation, and a shorter learning curve compared to conventional laparoscopy. For the patients, a quicker postoperative recovery, less postoperative pain, and lower blood loss compared to laparoscopy seems to emerge. This review summarizes all the published results of robotic assistance applied to cervical and endometrial cancer surgical management. [ABSTRACT FROM AUTHOR]

Depuis 20 ans, la coelioscopie est devenue une voie d’abord chirurgicale incontournable, particulièrement en gynécologie. Introduite depuis une dizaine d’années, l’assistance robotisée est de plus en plus utilisée, la chirurgie gynécologique oncologique constituant un éventail d’indications privilégié. Pour le chirurgien, ses avantages sont la restitution d’une vision en trois dimensions, l’absence de tout tremblement et donc une précision du geste plus grande (les instruments sont voués de sept degrés de libertéet permettant des mouvements à 360°), et enfin un apprentissage plus rapide que la coelioscopie conventionnelle. Pour nos patientes, les publications actuelles semblent en faveur d’une diminution de la morbidité (réduction des hémorragies peropératoires, diminution des douleurs postopératoires, durée d’hospitalisation plus courte). Dans cette revue de la littérature, nous faisons un état des lieux des résultats de l’assistance robotisée appliquée à la prise en charge des cancers pelviens. [ABSTRACT FROM AUTHOR]