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Our objective was to study the prognostic value of stoutness in non-metastatic breast cancer, from a population of French women.We constituted a large observational cohort of patients followed since a first unilateral breast cancer without distant dissemination. Stoutness was assessed using the body mass index (BMI, in kg/m(2)) at the time of diagnosis. Patients were classified into the four main categories of BMI, defined according to the World Health Organization recommendations. The risk of prognosis events was analyzed according to the BMI categories. To this end, survival analyses were achieved.The patients having a BMI value of at least 25 kg/m(2) presented significantly higher risks of death and metastasis recurrences when they were compared to the patients having a normal value of BMI. The multivariate analyses found a modest increase of risk, about 10 to 20%, depending on the degree of fatness. It reached about 20 to 50% according to the univariate analyses. The obese patients (BMIor= 30 kg/m(2)) had an increase of 50% of the risk of second primary cancers, comparatively to the patients having a normal value of BMI. Regarding contralateral, nodal and local recurrences, the survival analyses did not achieve any significant relationship with stoutness.A poorer prognosis is observed when breast cancer patients have a value of BMI that matches at least with overweight. Contrary to the results of few recent surveys, underweight patients do not present a poorer prognosis than normal weight patients. Excess of weight represents a modifiable factor in order to improve female breast cancer prognosis.

Breast cancer surgery has long consisted in the sole use of mastectomy. Then, it was proved that, in terms of global survival, conservative treatments associated with radiotherapies could give the same results. But breast deformations due to classic conservative treatments led some authors to use plastic surgery procedures: breast plastic surgery. Some breast plastic surgery procedures are well-known, others have been adapted to breast cancer treatment and more particularly in case of tumor of superior and internal quadrants. After the retrospective analysis of a series of 298 cases from the Institute Curie, the aim of this survey is to find whether there is a difference between: breast plastic surgery and usual treatments like mastectomy and classic conservative treatments. For most cases, the tumors were invasive ductal carcinoma and T2N0M0 carcinoma. This survey showed, among these cases, 94.56% of global survival, 86.81% of survival without metastasis and a five-year 93.47% without local recurrence, which is comparable to the results for mastectomies and classic conservative treatments. In selected cases, the use of mammaplasty could be interesting for breast cancer surgery treatment.

Since more than twenty years, methods of breast reconstruction using implants have continued to evolve in order to improve their aesthetic results. Shapes and materials of these implants have also evolved to obtain contours similar to that of the natural opposite breast. Therefore it can be considered that the use of asymmetric implants is the last step in implant technology before using made to measure implants. Asymmetric implants allow obtaining different contours in harmony to the different breast shapes according to the side, left or right, of the reconstructed breast which maximise the naturalness of the result. Such implants have an axis directed towards the exterior and lower part of the chest wall, are wider than high with a thinner part on their inner edge and a concave rear side moulding the curves of the chest wall. In our own experience, we placed more than 500 asymmetric implants. When analysing retrospectively the medical records of 156 patients, no distinctive features were observed when compared to symmetric classic implants in easiness in the surgical procedure or in complications except a slightly higher rate of seroma formation. When compared to usual implants the main benefits of asymmetric implants are: to offer a wider breadth, to slope down gently on their upper and inner sides according to their concave rear side, and therefore to better match subtle curves of a normal breast. Moreover such contours allow a distribution of the volume which fit better to the usual natural breast configuration of patients who underwent surgery for breast carcinoma. At last, such implants are easy to place and a very low rate of secondary rotation has been observed. In summary, for all these reasons, asymmetric implants, can be considered to be the class one in the choice of implants for breast reconstruction after breast surgery.

To report results of liver resections for breast cancer liver metastasis (BCLM) and to evaluate the rate of survival and the prognostic factors.Between 1988 and 1999, 69 patients were operated on for BCLM and 65 who had liver resection were analyzed. The selection criteria for surgery were: normal performance status and liver function test; radiological objective response to chemotherapy (and/or hormonotherapy); in cases of non-isolated BCLM, complete response of associated metastatic site (usually bone) and no brain metastases. The mean age of the 65 patients was 47 (30-70) years. BCLM was diagnosed an average of 60 (0-205) months after the initial cancer. The BCLM was more frequently solitary (n = 44). The mean diameter was 3.8 (0-12) cm. The mean number of cycles of chemotherapy before surgery was 7.5 (3-24). Liver resections included major hepatectomy (n = 31): right n = 19, extended left n = 4, left n = 8, minor hepatectomy (n = 25) and limited resection (n = 9).There was no postoperative mortality. The 18% morbidity rate included a majority of pleural effusions with two reoperations. The median follow-up was 41 months (6-100 months). The survival rate after surgery was 90% at 1 year, 71% at 3 and 46% at 4 years. Thirteen patients are alive at 4 years. The 36-month survival rate differed according to the time to onset of BCLM: 55% before versus 86% after 48 months (p = 0.01). The other studied factors were not statistically associated with survival. The recurrence rate in the remaining liver at 36 months differed according to the lymph node status of the initial breast cancer: 40% for N0-N1 versus 81% for N1b-N2 (p = 0.01) and according to the type of liver resection: 45% for minor liver resection versus 73% for major (p = 0.02).Adjuvant liver surgery should be included in multicenter treatment protocols for medically-controlled breast cancer liver metastasis.

Sentinel node detection in breast cancer can be realized with colorimetric and isotopic procedures often associated. The aim of this study was to report results obtained with blue dye injection only.From September 1998 to July 1999, blue dye injection was performed in 73 consecutive patients (mean age: 51 years, range: 36-71 years); 51/70 70% were post-menopausal and half of them were under substitute hormonal treatment; 70% of cancers were discovered through routine mammography. There were 12 bilateral cancers, six of them synchronous, and 84% of cancers were located in the external quadrants. Individualization of sentinel node was performed through blue dye injection into the tumor in case of preoperative diagnosis or in the tumoral site in case of discovery of the cancer through extemporaneous histological examination.71 out of 73 cancers were classified pT1 and 70% measured 10 mm and over. Individualization of sentinel node failed in two obese patients. Sentinel node invasion concerned one node (n = 7), two nodes (n = 1) and three nodes (n = 1). Conservative treatment was performed in 72 patients out of 73; in case of sentinel node invasion, axillary irradiation was performed without reoperation.Blue dye injection for sentinel node individualization is an accurate technique in selected patients in case of small tumors. Reoperation can be avoided and replaced by axillary irradiation in case of N+ tumors. Duration of hospitalization was 48 hours or under in 70/73 patients. Nevertheless isotopic procedure must be recommended as a routine technique in learning centers and for most surgical teams.

Sentinel lymph node (SN) biopsy is a recently developed, minimally invasive technique for staging the axilla in breast cancer. This new procedure of selective lymphadenectomy has been the subject of several studies, but there is not currently a consensus of opinion to define which is the best method of identification. At the Institut Curie since 1996, we have been using the Patent blue dye. The current series present the result of 122 patients with T1, T2, N0 or N1a breast cancer consecutively operated between december 1997 and august 1998. Sentinel nodes were identified in 107 out of 122 (87.7%) and accurately predicted axillary nodal status in 104 out of 107 (97.1%) cases. Three out of 35 node positive patients would have been missed with sentinel node biopsy alone, for a false negative rate of 8.5%. In all 3 cases, one lymph node presented with a micrometastases. In 15 cases out of 35 with metastatic axillary nodes, the only positive node was the SN (43%). The encouraging results of this study shows that it is possible to identify, in a large number of cases, the sentinel node by means of Patent blue dye only. This article detailed the technique used and reviews the literature concerning other methods of identification.

The sentinel node is defined as the first-line axillary lymphatic drainage node in breast cancer. If the sentinel node can be identified, during axillary dissection for breast cancer, resection could be limited reducing subsequent morbidity. However, before modifying the standard dissection procedure, it is important to prove that the sentinel node is representative of the metastatic status of other axillary nodes.Between March and December 1996, 86 patients (mean age 58 years, range 32-82) underwent amputation (n = 20), tumorectomy with dissection (n = 56) or tumorectomy followed by secondary dissection (n = 10) for breast cancer. Ten ml of diluted patent blue was injected either into the peripheral portion of the tumor or the tumorectomy cavity. Node dissection was performed 10 to 20 minutes after injection. The blue sentinel node was identified prior to standard dissection.A mean 12 nodes were removed (range 4-21). Seventy-nine sentinel nodes were identified (91%) and in 7 cases (8%) a sentinel node could not be identified. In 7 other cases the sentinel node was a false negative, i.e. non malignant despite metastases in other dissected nodes. In all the other cases, the status of the sentinel node predicted the status of the other nodes, i.e. a non-metastatic sentinel node associated with other metastatic nodes. Finally, in 7 cases, the sentinel node was the only invaded node among the nodes dissected. During the last 3 months of the study, the sentinel node was identified in 100% of the cases and was representative of the overall dissection.Identifying the sentinel node is an alternative to standard axillary node dissection procedures. The method requires a training period and identification can be improved with radioimmunologic guidance. Patient selection within the framework of a rigorous multidisciplinary protocol is indispensable. A nationwide study is currently being conducted to validate these preliminary results.

Surgery for hepatic metastases from breast cancer remains anecdotal and controversial. This retrospective series of 21 patients analyses survival after hepatic resection. These patients presented with isolated metachronous metastases, controlled by systemic treatment; surgery was considered to be an adjuvant treatment. There was no surgical mortality. The TNM stage of the initial breast cancer, the time to onset of metastases and the number of hepatic metastases did not influence survival. The 5-year survival, after diagnosis of metastatic disease, was 60%; clearly better than the expected survival. Eleven patients are currently alive without recurrence. Six patients developed a recurrence in the remaining liver after a mean interval of 12 months, including 4 patients who died after a mean interval of 49 months. These results suggest that a subgroup of patients with hepatic metastases from breast cancer may benefit from surgical resection. This surgery must be proposed in patients with isolated disease progression controlled by systemic treatment. In our experience, adjuvant surgery of hepatic metastases from breast cancer is followed by an uneventful postoperative course, improves survival and, in 50% of cases, allows discontinuation of chemotherapy, improving the patient's quality of life.

The treatment of recurrent non lactational breast abscesses is difficult. They occur with no apparent cause in young smoking patients. Twenty-two patients, mean age 40 years range 27-68, were treated over a period of 18 months by wide surgical excision with secondary spontaneous healing. No patient received post-operative antibiotics. Complete healing was obtained in 3-6 weeks. There were two recurrences with a follow up of 6-24 months. One patient developed a controlateral abscess which was treated by the same technique. No cosmetic defect was observed after complete healing. The duration of healing is upsetting for these young women, but the discomfort and pain induced by recurrent abscesses encourages them to accept this technique if properly and expertly counselled. The role of tabacco smoking seems to be the only cause of these recurring abscesses. All the patients (22/22) were heavy smokers.

A 35-year-old woman with a histologically proven T2 N0 M0 adenocarcinoma of the breast was given 4 cycles of neodjuvant chemotherapy then underwent tumourectomy followed by irradiation. Lymph nodes were free from invasion. A 7 cm ovarian cyst developed during follow-up and after a 2 month regimen of lynestrenol, coelioscopy with peritoneal lavage was performed. The pathology diagnosis was papillary cystadenocarcinoma requiring laparotomy which revealed invasion of both ovaries, neoplasic granulations and involvements of the epiloon. Exceresis of the trocar tract also showed tumoural invasion. Pathology examination favoured metastatic extension of the breast cancer. A 6-month chemotherapy was programmed before a second look. This case illustrates the risk of neoplastic dissemination after puncture or rupture of a cyst misdiagnosed as benign. In patients with a history of breast cancer, the risk of discovering a primary malignant ovarian cancer at coelioscopy is 9%. Metastases are found in 15-30% of the cases compared with 0.4 to 1.8% in unselected subjects. Prevention of operative dissemination relies on cystectomy without opening the cyst. This may require transforming the coelioscopy into a laparotomy which should not be considered as an operative failure but as a necessary method of preventing dissemination and clinical aggravation. Careful history taking, a rigorous coelioscopy technique and extension to laparotomy in cases with suspected diffusion should reduce the number of dramatic situations where the malignant process had not been suspected in the precoelioscopic diagnosis.

Axillary dissection in early breast cancer remains controversial because of its substantial side-effects and because its value with respect to recurrence or survival has not been unequivocally proven. Between 1982 and 1987, 658 patients were included in a prospective randomised comparison of lumpectomy alone with lumpectomy plus axillary dissection. All patients had a unilateral breast tumour not exceeding 3 cm in diameter and lymph-node involvement or metastases. Radiation therapy was given to both groups. The two groups of patients were similar with respect to mean age, TNM stage, and presence of hormonal receptors. Median follow-up was 54 months. 5-year survival of the patients was 94.2% (95% Cl: 92.1-96.4). There was a significant advantage in survival in the axillary dissection group (p = 0.014). Recurrence of tumour in the breast was similar in the two groups but visceral metastases, supraclavicular metastases, and lymph-node recurrences were less frequent in the axillary dissection group. Survival was related to the age of the patients (p = 0.005), the presence of positive nodes (p = 0.006), the histological grading (p less than 0.0001), and the presence of hormonal receptors (progesterone p = 0.0008, oestrogen p less than 0.0001). Treatment-adjusted relative risk was 2.4 (95% Cl: 1.3-4.2). The findings show that axillary dissection is justified for treatment of small breast cancers, although whether the better survival is due to axillary clearance itself or to adjuvant treatment for lymph-node involvement is unclear.

Pre- or postoperative radiation therapy reduces the incidence of local recurrence after surgical treatment of rectal carcinoma. Factors related to local recurrence were analyzed retrospectively by uni- and multivariate analysis. One hundred and fifty-five patients (mean age: 65 years) were operated on with curative intent between 1967 and 1984. Ninety-four patients (46 patients having abdominoperineal resections (APR), and 48 having anterior resections) did not receive radiation therapy. Sixty-one patients had preoperative radiation therapy followed by APR in 59 cases. Univariate analysis showed that the risk of local recurrence increased significantly with male sex (p less than 0.006), positive lymph nodes (p less than 0.01), vascular invasion (p less than 0.02), and Astler-Coller classification (p less than 0.05). Tumor located at less than 5 cm from the anal verge was significantly related to recurrence only in patients not receiving radiation therapy (p less than 0.02). Multivariate analysis including therapeutic modalities showed that local recurrence was significantly related with male sex (p less than 0.02), positive lymph nodes (p less than 0.01), and distance to anal verge (p less than 0.01). The beneficial role of radiation therapy appeared only for tumors located 5 cm or less from the anal verge. Prognostic scores were established using these variables and the effect of irradiation was evaluated according to these scores. Radiation therapy significatively reduced the risk of local recurrence in low-risk patients, i.e., female with low-lying tumor and with negative lymph nodes (p less than 0.03).(ABSTRACT TRUNCATED AT 250 WORDS)

The study of cases treated between 1970 and 1984 at the Institut Curie, in women aged 40 years and under, was undertaken in order to determine the influence of age on prognosis. The incidence of these cases was stable throughout the 15 years study period as was the very high incidence of earlier cases: 84.5%. Earlier cases were treated with combined radiotherapy and surgery and advanced cases with radiotherapy alone. Overall survival rate was 75% at 5 years, 60% at 10 and 15 years: but 85% for the 36-40 years of age group, 74% for the 30-35 years of age group and 67% for women aged 29 and less. Five year survival rate for operated cases is the same for the 36-40 age group as for all age patients, according to the lymph node status. In contrast, it was 85% in the N-younger group, and 30% for those patients with lymph node involvement. In conclusion, from our study it appears that the overall survival rate for women of 36 years and less, and mainly 29 years and less, is significantly lower than that for older women, and that their prognosis is especially poor in the case of lymph node involvement.

Since surgical gastrostomy is not a risk-free operation in debilitated patients, a method of endoscopic percutaneous gastrostomy (EPG) is proposed. A thread is passed percutaneously into the gastric cavity and brought to the exterior through the mouth during fibroscopy. This thread allows removal of a gastrostomy tube by simple traction. Used in 18 patients with ENT cancer the EPG was simple to perform, postoperative complications being minor in 3 cases and serious in one patient. In the absence of any obstacle in the pharyngeal channel preventing the passage of a fibroscope, EPG is a simple procedure and is therefore an alternative to surgical gastrostomy.

For several authors, DNA tumoral cell content represents an important prognostic factor in colorectal cancer. Samples obtained from 65 human colorectal cancers operated on between 1983 and 1986 were studied. Of 52 cases studied by flow cytometry 60 p. 100 were aneuploid tumors. The proliferative index was calculated in slightly over 50 p. 100 of the cases by DNA histogram analysis. During the same period 30 tumoral karyotypes were established by cytogenetic analysis. In 17 cases a comparison was possible between flow cytometry and cytogenetic results. In all cases a significant correlation was seen between the DNA histogram modal value and the mean number of chromosomes counted by cytogenic analysis. In this study, there was no statistical correlation between flow cytometry results and Dukes classification. Because of the short follow-up in our series, no prognostic value may be attributed to the DNA index.

Pre-operative irradiation in operable cancer of the rectum remains controversial. This is a report of a retrospective study about 192 patients treated between 1958 and 1980 at the Institut Curie (Paris) for a rectal cancer. An abdomino-perineal resection was done in 144 patients, 83 as a primary procedure and 61 after a pre-operative irradiation. During the same period 48 patients had an anterior resection. We put in this study the only patients who underwent curative surgery. Irradiation was given with high voltage by a four field "box technique". The tumour received 40 to 50 grays in 5 to 6 weeks. The operation was done at least 6 weeks after the end of the irradiation. There was no difference for the sex, and age of the patients, and in the size of the tumour before treatment, between the patients irradiated and those operated on as a primary procedure. There was no difference in the operative mortality as well as the 3, 5, and 10 year survival in the two groups. Pre-operative irradiation did not change the number of perineal recurrences or the number of visceral metastases. The healing of the perineum was significantly longer in the irradiated patients (p less than 0.001). The survival was closely related to the Dukes classification. The number of Dukes A patients was significantly higher (p = 0.02) after irradiation: 26/61 (43%) vs 19/83 (23%) when the patients were not irradiated. In our experience pre-operative irradiation can shrink some large tumours helping the surgical act.(ABSTRACT TRUNCATED AT 250 WORDS)

Evidence of blood in discharge from one breast and from one duct in an indication to operate on for most surgeons. We have used hemoccult to demonstrate the presence of blood in certain discharges. Discharge cytology was systematic and when it was possible a correlation was done with the operative specimen. 55 patients were studied. In 23 cases hemoccult was positive and there was blood on the cytological smear. In 28 cases hemoccult was negative and the cytological smear showed no blood. In the remaining 4 cases the hemoccult was positive but the cytological smear failed to show any blood. There was no false negative test. There were three breast cancers. Among this series of 55 patients and the test was positive in each case. Using slides of hemoccult to detect blood in a nipple discharge is rapid and simple can be done in the doctor's office. However, the results of the test have to be strictly correlated with other elements of the work up in particular with mammography and galatography.

The fifth case of a common bile duct carcinoid tumor is reported. The importance of endoscopic retrograde cholangiography on the one hand and specialized staining on the other for diagnosis is emphasized. The slow growing nature of these tumors favors extensive surgery whenever possible.

Twelve recurrences after surgical treatment of 83 cystosarcoma phyllodes of the breast were reported. The histology of the initial tumor was benign (n = 73), borderline (n = 6), sarcoma (n greater than 4). Nine recurrences were observed at the initial site of the tumor (2 in another quadrant of the same breast and I in the contralateral breast). The cause of local recurrence is related to incomplete tumorectomy (n = I), pseudo-capsule infiltration (n = 3), micro-nodules satellites (n = 2). No etiology for recurrence was defined in 3 cases. The importance of a careful microscopic examination of the initial tumor is emphasized because the infiltration of the pseudo-capsule and the presence of micro-nodules satellites can only be recorded on correctly prepared slides.

Closed suction drainage is widely used after modified radical mastectomy to prevent accumulation of serum or lymph and to promote adherence of the skin flaps to the chest wall. However, between 5 and 35% of the patients develop seroma, which may prolong their stay in hospital and require more frequent post-operative outpatient visits. The prospective study reported demonstrate a significant correlation between the incidence of post-operative seromas, the duration of suction drainage and the amounts of fluid drained. The incidence of seroma also correlated significantly with the patient's age, the size of the breast removed, the presence of arterial hypertension and the post-operative use of heparin. Pre-operative radiotherapy and the TNM type of the tumour had no effect on the duration and volume of drainage nor on the occurrence of seromas. A drainage of short duration and a short stay in hospital are advocated for most mastectomy patients. Delayed mobilization of the shoulder should decrease the volume of accumulated fluid and the incidence of seromas.

Between 1968 and 1982, 195 patients with invasive anal canal carcinoma were treated at Institut Curie (Paris, France). There were 168 females and 27 males --sex-ratio: 5.7/1, mean age: 67 +/- 11 yrs. (range: 38-85 yrs.). The initial size of the tumors was analyzed according to the circumferential invasion of the anal canal. The tumor involved 1/4 of the circumference in 49 cases, 1/2 of the circumference in 108 cases, 3/4 of the circumference in 22 cases and the whole circumference in 16 cases. Pathological examination revealed 20 cloacogenic carcinomas and 175 squamous carcinomas. All patients received radiotherapy as initial treatment and none received chemotherapy as a curative procedure. Eight patients received only palliative treatment. Twenty-seven patients were operated on because the response of the tumor to irradiation was partial or incomplete. One hundred and sixty patients received the full course of irradiation with a complete response. Among the latter, 100 patients were alive NED with a normal anal function with at least a 2-year follow-up. Local recurrences (n = 42) underwent salvage surgery in 50 p. 100 of the cases with a 3-year survival over 50 p. 100. Actuarial survival of the 195 patients was 68.5 p. 100 at 3 years and 58 p. 100 at 5 years. Survival was highly related to the initial size of the tumor and to the presence of positive inguinal nodes (p less than 0.0002). The histologic type was not related to the response to radiotherapy, nor to local recurrence or to survival.(ABSTRACT TRUNCATED AT 250 WORDS)

Cytogenetic study of 11 cases of colorectal carcinoma was performed after R-banding. In all instances, there was a rearrangement involving chromosome 17 in its juxtacentromeric region, leading to the loss of its short arm. There was also a relative lack of chromosome 18, unrelated to a rearrangement of this chromosome in all but one case. Other anomalies, involving chromosomes 1 and 8 among others, were frequently but not systematically observed. The consistent lack of chromosome 18 and of the short arm of chromosome 17, leading to a complete or partial monosomy of these chromosomes in near diploid cells suggests that the passage to the hemizygous status of recessive genes carried by these chromosomes may play an important role in the development of colorectal carcinoma.

Since angiosarcoma of the breast was first reported in 1907 fewer than one hundred cases have been reported. They are primary malignant vascular mesenchymal tumors occurring in young females. Their prognosis is very bad. We report here six new cases treated at the Institut Curie between 1972-1983. The mean age was 33, range 27-40. One tumor was a low grade one and the five others of breast, were high grade tumors. We carried out four amputations three associated with radiotherapy and/or chemotherapy and the fourth one did not received adjuvant treatment. In the two others cases the diagnosis was made when the patients were already suffering from polymetastatic disease. The mean survival was 17 months, the range 5-44 months. Recent reviews of the pathologic material made it possible to differentiate three grades in these tumors. The prognosis was correlated to the degree of differentiation. Recently hormonal receptors have been described in soft tissue sarcomas. The value of levels of these receptors in breast angiosarcoma Is discussed.