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Introduction/Background*The COVID-19 pandemic has turned the standard of care of medicine worldwide into a “public health emergency of international concern. “Cancer patients are a unique population in that they are vulnerable to COVID-19, particularly if immunocompromised, and also, their oncologic outcome is based on the type and timing of the treatment.MethodologyA retrospective review comparing all surgical activities between the year before COVID-19 and the year after.This study was conducted in the Surgical Oncology Department in Salah Azaiez Institute of Oncology, the reference cancer care center in Tunisia.Result(s)*In our center, we created a new surgical procedures team.There was a significant reduction in the median daily breast surgery, superficial surgery, and ambulatory surgery (< 0,001). But not all operation types decreasing in frequency.Three months after COVID -19, we selected patients for laparotomy and decreased our activity by 50%.Starting from June 2020, we have increased our activity to exceed that of 2019. No increase in mortality or morbidity from treatment during COVID-19 for operated patients.The total surgically consults volume decreased by 36,17% in the post-COVID-19 period, significantly reducing the median daily consult volume (p

Ovarian cancer has the worst prognosis of all gynecologic malignancies. The standard treatment of patients with ovarian cancer is a multidisciplinary assignment involving aggressive surgery with or without chemotherapy. Among the prognostic factors, the residual disease is of capital importance. Surgical outcomes, including the amount of residual disease, would be better if the surgical oncologist performed it. This optimal surgical treatment according to guidelines may provide the most important benefit in survival. This current review aims at highlighting the positive relationship between complete cytoreductive surgery and survival. Patients with OC should be referred to surgical oncologists providing high-quality comprehensive care.

Introduction. One case out of 3 cases of primary ovarian cancer is diagnosed at an early stage. Almost 15% of ovarian cancers are diagnosed in women who are within the range of procreation age, raising the debate on the feasibility of fertility-sparing surgery (FSS) for those tumors. In the case the patient is admitted with stage 1A or 1B in most histologic types, it is still controversial in stage 1C. Results and Discussions. This is an eight-patient-case series. The median age is 27 years old (ranging from 18 to 42). The main clinical manifestation was pelvic pain (87.5%). Four patients (50%) presented with tumor torsion. All patients underwent FSS; five of them (62.5%) had conservative staging, two (25%) underwent salpingooophorectomy and one (12.5%) ovariectomy, type histo + stade Figo. The chemotherapeutic treatment was administered to four patients (50%) following surgery without major side effects. One patient (12.5%) presented a loco regional recurrence that occurred 14 months later. She was treated with combined chemotherapy and radical surgery. One patient out of eight (12.5%) achieved a natural pregnancy after the treatment and another one (12.5%) was submitted to an assisted reproductive procedure which did not result in a viable pregnancy. Conclusion. FSS seems to be a suitable approach for stage 1C ovarian cancer. However, more case series and meta-analyses should be conducted.

Aim: To investigate the prognostic significance of clinical and pathological factors of non-metastatic renal cell cancer after surgery. Patients and methods: We conducted a retrospective cohort study based on the records of patients with non-metastatic renal cancer submitted to radical or partial nephrectomy between 2000 and 2015 in Salah-Azaiez Institute. Results: Median follow-up was 38 months (interquartile range: 20–64). Five-year overall and disease-free survival were 53.8% and 43.1%. In the multivariate setting, lymph node invasion (p = 0.01), clear cell renal carcinoma subtype (p = 0.014), and tumor necrosis (p = 0.009) were the only independent statistically significant predictors of disease-free survival, while Fuhrman grade (p = 0.025), clear cell renal carcinoma subtype (p = 0.044), and TNM stage (0.041) were the only factors correlated with overall survival. Conclusion: For patients with non-metastatic renal cell carcinoma, independent predictors of disease-free survival and overall survival were clear cell renal cell carcinoma, Fuhrman grade, TNM stage, lymph node invasion, and tumor necrosis. Such information could be used to guide the intensity of follow-up and identify high-risk patients who can be targeted for adjuvant therapy trials.

There is limited research suggesting that women with Benign Breast Disease (BBD) experience psychological distress similar to breast cancer (BC) women. We aimed to examine hopelessness and its related factors in BC and BBD women.This was a cross-sectional study. The Beck Hopelessness Scale and the Beck Depression Inventory were administered to 51 BBD and 52 BC women.BC women had higher hopelessness scores as compared to those with BBD (6.9 ± 4.8 vs. 4.9 ± 3.6;We found that not only BC but also BBD lead to a psychological burden. Early detection and handling of hopeless feelings and thoughts that may arise in this population are recommended.

Introduction The sentinel lymph node (SLN) concept represents advancement in the management of the endometrial cancer (EC). We aim to assess the performance of the SLN procedure; its positive predictive value (PPV) and negative predictive value (NPV); in stage I of EC (FIGO2009). Method A prospective study is conducted in our institution. We perform a double detection of the SLN (radiolabel Tc 99 microsulfur colloid and a color method using patent blue) followed by pelvic lymphadenectomy with or without paraaortic lymphadenectomy. A pelvic MRI is performed to determine myometrial invasion and nodal status. The injection of Tc 99m colloid occurs the day prior to surgery. The injection into the stroma of the cervix at the 3 and 9 o'clock positions was performed by an oncologist surgeon with the assistance of a nuclear medicine physician. Preoperative lymphoscintigraphy was obtained after 90-120 minutes. We inject into the cervical stroma 2cc of patent blue similar to the Tc99 injection. A gamma detecting probe is used to locate radioactive lymph nodes. The SLNs identified then are labelled as radioactive and/or blue. No frozen-section analysis was performed. Results For the pathological analysis of the SLN, Haematoxylin Eosin is used. If there is no metastasis detected, an ultra staging protocol using different anti-cytokeratines is conducted. Studies have shown that this approach is possible having satisfactory results when conducted by dedicated surgical, radiology and pathology team. We look forward to our outcomes to illustrate those results. Take-home message Sentinel lymph node is a good alternative for gynecological cancer

Background Male breast cancer (MBC) is a rare and neglected disease. Prognostic and predictive factors in MBC are extrapoled from trials conducted on its female counterpart. Objective Since the relationship between the transcription factor Forkhead box M1 (FOXM1) expression and the clinical response to chemotherapy and hormonotherapy in MBC remains unknown, we sought to investigate the predictive value of FOXM1 in MBC. Methods FOXM1 expression was assessed in 130 MBC cases. Clinical significance was analyzed by Kaplan Meier curves, log-rank test and multivariate Cox regression analyses. Results Patients with high FOXM1 expression had a significantly lower response rate to chemotherapy (P = 0.045) and hormonotherapy (P = 0.029) than those with low FOXM1 expression. Multivariate analyses indicated that FOXM1 was an independent prognostic factor for disease free survival in MBC patients (P Conclusions FOXM1 may have a reliable predictive significance in male breast cancer and thus may become an important target for male breast cancer therapy in the near future.

Background Growing evidence have shown promise for targeting programmed death-1 (PD-1)/programmed death-ligand 1 (PD-L1) signaling in several tumors. In female breast cancer, PD-L1 expression has been correlated with poor clinical outcome. However, whether PD-L1 has any indication for prognosis in male breast cancer (MBC) patients remains unknown. The purpose of this study was to examine the expression levels of PD-L1 in MBC and to identify the relationship between PD-L1 expression and patient survival. Methods We retrospectively identified 110 male breast cancer patients diagnosed between 2000 and 2013 at Salah Azaïz Cancer Institute. PD-L1 expression was evaluated by immunohistochemistry (IHC) using CD274 antibody. Specimens were scored as IHC low or high, when < 5% or ≥ 5% of cells were PD-L1 positive, respectively. The association between expression of PD-L1 and survival was investigated using Kaplan-Meier survival and COX proportional hazard regression analyses. Results Median follow up was 12.5 months [range 1-132 months]. High expression of PD-L1 was observed in 64.5% of MBC samples (71/110). PD-L1 expression was significantly associated with advanced clinical stage (p=0.012), higher histological grade (p=0.014), higher Ki67 expression (p=0.023) and hormone-receptor negative status (p=0.024). Patients with high PD-L1 expression had significantly shorter overall survival (OS) than patients with low expression (p=0.002, hazard ratio (HR) =5 [2.624–10.642]). Multivariate analysis identified PD-L1 as an independent prognostic factor for OS (p Conclusion Our results indicate that high PD-L1 expression may be a prognostic indicator for reduced OS. Thus, PD-L1 expression is a promising novel biomarker with prognostic significance in MBC and may suggest a potential therapeutic target of anti-PD-L1 antibody therapy in MBC patients. Citation Format: Abdeljaoued S, Bettaieb I, Adouni O, Goucha A, Chiba D, Bouzaiene H, Ben Hassouna J, Boussen H, Rahal K, Gamoudi A. Prognostic value of PD-L1 expression in male breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P5-23-05.

El cancer de mama inflamatorio representa una entidad agresiva de cancer de mama, clasificada como T4d, relativamente frecuente en Tunez y en el norte de Africa (5-7%) y mas rara en Europa y Estados Unidos (1-2%). El diagnostico clinico se basa en la presencia de signos inflamatorios cutaneos: dolor, edema, piel de naranja y/o eritema. El diagnostico positivo es histologico y se efectua despues de la biopsia de la afeccion cutanea y/o del tumor mamario subyacente. La histologia, la inmunohistoquimica y la genomica muestran una frecuencia mas elevada de cancer triple negativo o que sobreexpresa HER2. El estudio de extension locorregional y a distancia se basa en la exploracion fisica, la mamografia y la ecografia mamaria bilateral, la resonancia magnetica mamaria, la tomografia computarizada de cuerpo entero y la tomografia por emision de positrones con fluorodesoxiglucosa. El proceso diagnostico y terapeutico es multidisciplinario y se basa en la quimioterapia neoadyuvante, asociada a la terapia dirigida anti-HER2 en caso de sobreexpresion del oncogen HER2, seguida de una cirugia radical oncologica y, despues, una radioterapia locorregional. Por otra parte, el tratamiento comporta la continuacion de la terapia dirigida anti-HER2 con una duracion total de 1 ano y el inicio de un tratamiento hormonal si los receptores hormonales son positivos. La aportacion de la quimioterapia neoadyuvante secuencial con antraciclinas y taxanos asi como las terapias dirigidas anti-HER2 han mejorado considerablemente el porcentaje de control locorregional, asi como la supervivencia global y sin enfermedad del cancer de mama inflamatorio, actualmente superior al 40% a los 5 anos.

Objectives The aim of this study was to identify predictive factors of axillary lymph node metastasis (ALNM) in early breast cancer (EBC). Methods It was a retrospective study of 209 patients with T0-T1-T2 breast cancer who underwent resection of the primary tumor and axillary staging by sentinel lymph node biopsy (SLNB) and/or axillary lymph node dissection (ALND) over 2012 at our institute.The χ2 test and Fisher’s exact probability tests were used for categorical variables,and t-test for continuous variables.Predictors of ALNM were identified by univariate and multivariable logistic regression analyses using SPSS statistical software package (version 20.0). Results Among the 209 patients, 48.8% (102 cases) had ALNM.Factors associated with ALNM in univariate analyses were tumor clinical size (23.5% in stage T0,41.9% in stage T1,55.4% in stage T2; p=0.02),multifocality (73.7% vs 43.3%,p=0.001),lymphovascular invasion (LVI) (77.1% vs 43.1%,p Conclusions Our results suggest that LVI, tumor size and the rate of positive ER are predictive factors for ALNM in EBC.

Objectives Because primary carcinoma of the vagina comprises less than 2% of all gynecologic malignancies, the management of metastasis is not well know. Methods We reported the surgical management of metastasis of primary vaginal in 2 patients treated in Salah Azaiz institute on 1994 and 2006. Results The first patient was 37 years old and had a primary neuroendocrine tumor of vagina and the second patient was 68 years old and had a primary adenocarcinoma of vagina. The first patient was staged as stage I of FIGO and the second as stage IV of FIGO. The two patients underwent surgery as primary treatment followed by chemoradiotherapy. And they were free of disease. Fourteen years later, the first patient developed a lung metastasis managed with surgery and oncologic results were successful (lived for 3 years after). The second patient developed a brain metastasis managed with surgery and followed by prophylactic radiotherapy; the patient was free of disease during her follow up period (2 years). Conclusions We reported a successful surgical management of metastasis of primary vaginal carcinoma in two patients; our findings seem to be interesting due the lack of data about the management of those metastasis.

Fibroadenomas are the most common breast disease that occurs usually in young. The coexistence of an invasive ductal carcinoma and a fibroadenoma in the ipsilateral breast is extremely rare. We present the case of a 52 years woman, presented to us for an upper-outer breast lump. Breast imaging concluded to tow contiguous lesions, one of them was suspicious. She had a conservative surgery. Histology concluded to a fibroadenoma and an invasive ductal carcinoma.

Background Several studies have demonstrated that the presence and the amount of tumor-infiltrating lymphocytes (TILs) are a potential biomarker of prognostic significance in some solid tumors. Data suggests that high levels of TILs are associated with favorable prognosis. However, whether TILs have any indication for prognosis in male breast cancer (MBC) patients remains unknown. In this study, we investigated the relationship between the expression and degree of CD8+ TILs, CD4+ TILs, and TILs and evaluated the prognostic value of these three factors in MBC. Methods We retrospectively identified 110 male breast cancer patients diagnosed between 2000 and 2013 at Salah Azaïz Cancer Institute. Stromal (str) CD8+ and CD4+ TILs were evaluated immunohistochemically. Two pathologists independently evaluated TILs levels using H&E stained slides following 2014 International TILs Working Group guidelines. Kaplan Meier and univariate and multivariate Cox regression analysis were applied to determine the association of CD8+ TILs, CD4+ TILs and TILs with clinicopathological features and overall survival (OS). Results The median for presence of str-CD8+TILs was 7% (0%-40%), str-CD4+TILs was 2% (0%-20%) and str-TILs was 10% (1%-40%). Only 12% of MBC patients had high str-CD8+TILs and 11% had high str-CD4+TILs. Fifty three percent had low str-TILs and 47% had moderate str-TILs. No lymphocyte predominant breast cancer was identified. Regarding intrinsic molecular subtypes, TNBC subtype and HER2 enriched tumors compared with Hormone receptor positive tumors had higher median levels of str-CD8+TILs, str-CD4+ TILs and str-TILs at diagnosis. However, increased level of str-CD8+ TILs, str-CD4+TILs and str-TILs weren't associated with improved OS in IHC subtypes (p=0.597, p=0.498 and p=0.456 respectively). On univariate analysis, higher levels of str-CD8+TILs, str-CD4+ TILs and str-TILs were associated with better OS (p=0.035, p=0.043 and p=0.040 respectively). Multivariate analysis identified str-CD8+ TILs and str-TILs as independent prognostic factors for OS ([HR= 0.851 (0.706-0.997), p=0.000] and [HR= 0.69 (0.43-0.96), p=0.045] respectively) but not str-CD4+ TILs (p=0.276). A high level of str-TILs was correlated with high str-CD8+ (p = 0.025). Conclusion The level of TILs in male breast cancer is low, suggesting prominent immune regulation/suppression in this disease. Str-CD8+ T cells and str-TILs represent potential prognostic markers in male breast cancer patients. Citation Format: Abdeljaoued S, Bettaieb I, Adouni O, Goucha A, Ghozzi R, Bouzaiene H, Hdiden M, Ben Hassouna J, Makhlouf R, El Benna F, Boussen H, Rahal K, Gamoudi A. Prognostic significance of CD8+ tumor-infiltrating lymphocytes (TILs), CD4+ TILs and TILs in male breast cancer [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 P3-15-01.

Background Malignant ovarian germ cell tumor is a rare type of disease, which generally has a good prognosis due to the high chemosensitivity of this type of tumor. Fertility preservation is an important issue because malignant ovarian germ cell tumor commonly affects young women. Although conservation is the standard for early stage, it becomes more debatable as the disease progresses to more advanced stages. Aim: Report the case of a patient with an International Federation of Gynecology and Obstetrics Stage IIIc malignant ovarian germ cell tumor, who had conservative surgery and chemotherapy with a good fertility outcome. Case presentation A 23-year-old North African woman with a left malignant ovarian germ cell tumor stage IIIc was treated by left adnexectomy and omentectomy followed by chemotherapy. A 15-year follow-up showed no signs of relapse, and she completed three full-term natural pregnancies. Conclusions Malignant ovarian germ cell tumor is a rare ovarian tumor with a good prognosis. It is usually associated with a good fertility outcome in early stages. However, due to the rarity of the disease in advanced stages, the fertility outcome for this group of patients is not clear. This lack of data surrounding advanced stages points to the need for a meta-analysis of all published cases.

Ovarian Sex Cord Stromal Tumors (SCST) are a rare disease carrying a good prognosis. They generally affect young women; therefore fertility preservation is a critical issue. Fertility Sparing Surgery (FSS) showed promising results in both oncologic safety and fertility preservation. A retrospective case series involving 9 patients diagnosed with SCST and treated with fertility sparing surgery at our institution was conducted between January 2000 and May 2015. The median age was 24 years old (10 to 39). The main clinical manifestation was pelvic pain seen in seven patients. Five patients complained about menstrual cycle disorders. The nine patients went through fertility sparing surgery; seven had conservative staging and the other two had a unilateral salpingo-oophorectomy. Three patients out of nine had a pelvic unilateral lymphadenectomy. Two patients received adjuvant chemotherapy. Only two patients presented locoregional recurrence that occurred respectively after 7 and 192 months. The treatment combined chemotherapy and surgery based on mass resection. One patient achieved a natural pregnancy after the treatment. FSS seems to be a suitable approach for SCST. However, more case series and meta-analysis should be conducted.

Background The Forkhead box M1 (FOXM1) transcription factor is known to play an important role in the development and progression of many cancer types including breast cancer. The important role of FOXM1 in cancer affirms its significance for clinical use and therapeutic intervention. Elevated expression of FOXM1 in female breast cancer correlates with undifferentiated tumor phenotype and negative clinical outcome. However, whether FOXM1 has any indication for prognosis in male breast cancer (MBC) patients is still unknown. The purpose of this study was to examine the expression levels of FOXM1 in MBC and to identify the relationship between FOXM1 expression and patient survival. Methodsl Immunohistochemical analysis for FOXM1 was performed in a total of 80 male breast cancer specimens, all with linked clinical outcome data. Kaplan-Meier method and Cox proportional hazards analysis were used to relate FOXM1 expression to clinicopathological variables and overall survival (OS). Results We observed high expression of the FOXM1 protein in 39 % of MBC samples (31/80). FOXM1 overexpression was significantly associated with higher histological grade (p=0.05), lymph node metastasis (p=0.04), tumor size (p=0.05), and estrogen receptor expression (p=0.04). Patients with FOXM1 expression had a significantly poorer overall survival than those without FOXM1 expression (p=0.02). Multivariate analyses indicated that FOXM1 positivity was an independent prognostic factor for OS (p=0.03). Conclusion These results show that FOXM1 may represent a novel MBC marker with prognostic significance that could be included into the limited marker panels for MBC. Citation Format: Rahal K, Abdeljaoued S, Bettaieb I, Bouzaiene H, Adouni O, Miladi S, Goucha A, Bouaziz H, Makhlouf R, Hechiche M, Benna F, Boussen H, El May A, Gamoudi A. Overexpression of FOXM1 is a potential prognostic marker in male breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-19-03.

Background Histologically, node-negative breast cancer generally have a good prognosis. However, 10 to 30% of the cases present local relapses or metastasis. This group of people has high chances of remission if detected early. The aim of this study is to identify financial affordability for developing countries to adjust treatment. Methods We selected 405 patients with histologically confirmed node-negative breast cancer in our institution between January 2001 and December 2003. Patients with metastasis were excluded. The statistical analysis was conducted using SPSS ver. 18 (SPSS, Inc., Chicago, Illinois). Results The medial age was 51 years old. The medial tumor size was 35.4 mm. Clinically, 67.2% of the patients were staged cT2 and 63.2%, cN1i. Breast conservation was achieved in 41% of cases. In the histologic examination, the medial size was 30 mm. Grade III tumors were found in 50.1% of patients and positive hormonal receptors in 53.4%. The mean number of lymph nodes was 14. Eight patients had neoadjuvant chemotherapy. Adjuvant locoregional radiation and adjuvant chemotherapy were prescribed respectively in 70.6 and 64.4% of cases. 59.7% had adjuvant hormonal therapy. The follow-up showed 17.7% cases of relapse either locally or in a metastatic way in a mean time of 57.4 months. The disease-free survival at 5 years was 82.1%, and the overall survival for the same period was 91.5%. The histologic tumor size and the grade and number of lymph node dissected were shown to be influencing the disease-free survival. Radiation therapy and hormone therapy showed improved disease-free survival and overall survival. Conclusion Our study found interesting results that may help personalize the treatment especially for patient living in underdeveloped countries, but further studies are needed to evaluate those and more accessible prognostic factors for a more accessible healthcare.

Introduction The conservative surgery is more and more indicated for breast cancer. However, we still fear local recurrence which is mostly due to residual tumors?. Several techniques have been used to minimize theses residual tumors; one of them is the systematic circumferential tumor cavity shaving (SCTCS). Methods We sampled 75 female patients who had conservative surgery with positive shaved margins in the anatomopathology examination and to whom a complementary treatment with mastectomy have been decided. Results The median age was 48 years old. The median tumor size was 23 mm. In the histological examination of the tumors, 93% were invasive ductal carcinoma associated in 50% of the cases to the presence of ductal carcinoma in situ (DCIS) where all the lumpectomies had clear margin. For the SCTCS, 62,2% were DCIS and in 17,6% of the cases were invasive ductal carcinoma. A complementary treatment with mastectomy was indicated to all the patients. A residual tumor was detected in the remaining mammary gland in 47,7% of the cases out of which 50% were DCIS. Local recurrence happened in three patients (4,6%) after a median of follow up of 36 months. The overall survival and the disease free survival at five years were respectively 83,6% and 75,5%. Conclusion Standardized lumpectomy cavity shaving provides a backup to lumpectomy margins in conservative breast surgery but it can also be used as a sample for the remaining breast, helping to detect the residual tumor, and decreasing the rates of local recurrence after BCT.

Resume Introduction Les angiosarcomes du sein sont des tumeurs vasculaires rares. Elles representent 0,4 % de l’ensemble des tumeurs malignes du sein et 3 a 9 % des sarcomes mammaires. Patients et methode Il s’agit d’une etude retrospective portant sur dix cas d’angiosarcome (neuf femmes et un homme) du sein colliges au service d’immuno-histocytologie de l’hopital Salah Azaiez sur une periode de 31 ans entre 1977 et 2007. Resultat La moyenne d’âge etait de 40 ans. Le mode de decouverte a ete un nodule du sein avec un etat general conserve dans tout les cas. La taille moyenne de la tumeur etait de 5,5 cm. La mammographie a revele une masse bien limitee dans cinq cas. Une mastectomie a ete pratiquee chez huit patients associee dans quatre cas a une radiotherapie et dans un cas a une chimiotherapie. Le traitement conservateur a ete indique dans deux cas. L’examen histologique a montre un aspect typique d’angiosarcome dans huit cas. La survie sans recidive allait de quatre mois a 13 ans. Deux patientes ont ete perdues de vue apres le diagnostic d’angiosarcome. Quatre de nos patients n’ont pas developpe de recidive locale ou de metastase a distance. Deux patientes ont developpe une recidive locale ou de metastase a distance. Deux patientes ont developpe une recidive locale apres huit et 18 mois. Une patiente a developpe une metastase osseuse apres 29 mois. Conclusion Les angiosarcomes du sein sont des tumeurs rares qui posent un probleme diagnostique differentiel avec les angiomes. En consequent, une surveillance rapprochee et reguliere s’impose pour les tumeurs vasculaires.

The treatment of soft tissue sarcomas of limbs should be discussed within an experienced multimodality team. Surgical resection remains the cornerstone of therapy for localized disease and achieves a five years overall survival around 75% and a local recurrence rate as low as 10% in the best series. In complex cases, neo-adjuvant treatments may be used such as systemic chemotherapy, isolated limb perfusion, or radiotherapy to achieve an optimal conservative approach. Molecular genetics of sarcomas and quality of margins are essential to guide diagnosis and therapeutic selection. In case of marginal or incomplete resection, a new enlarged surgical resection should always be discussed before administration of any adjuvant treatments. Many retrospective studies and two randomized studies (one of adjuvant brachytherapy and one of external beam radiotherapy) have shown that adjuvant radiotherapy after complete surgery significantly reduces the risk of local recurrence in extremity soft tissue sarcomas. A randomized study has compared pre- to postoperative radiotherapy. The results in terms of local control are similar in both arms. The risk of surgical complications is higher in the preoperative arm and the risk of late sequelae is higher in the postoperative arm. A randomized study within the French sarcoma group is ongoing evaluating the omission of postoperative radiotherapy in favourable cases. Presently, the role of systematic first-line invasive treatment (including surgery and/or radiotherapy) of desmoids is debated. It is becoming evident that up to 50% of patients with desmoids benefit from a front-line non-aggressive policy, because growth arrest is a common feature of this disease. Additional study of the molecular determinants of desmoid behaviour is needed to guide treatment.

Resume Objectif Le carcinome medullaire typique du sein est une forme clinique particuliere par sa rarete — moins de 5 % de l’ensemble des cancers du sein — ses aspects cliniques, histologiques, radiologiques particuliers et son evolution favorable. Notre objectif, a partir d’une serie rare est de souligner egalement ces particularites. Patientes et methodes Etude retrospective portant sur 33 patientes traitees a l’institut Salah-Azaiz (ISA) durant une periode de six ans, allant de 1994 a 1999 pour carcinome medullaire typique du sein, confirme histologiquement selon les criteres de Ridolfi. Resultats L’âge moyen des patientes etait de 47,5 ans avec une atteinte predominante du sein gauche (55 %) et des quadrants superieurs (66 %). La taille tumorale moyenne est de 46 mm. Dans notre etude, 61 % des patientes ont eu une chirurgie radicale, 73 % une radiotherapie, 57 % une chimiotherapie et 42 % une hormonotherapie. Le taux de survie a cinq ans sans rechute etait de 85 %. Discussion et conclusion Le carcinome medullaire typique du sein est une forme rare des tumeurs malignes mammaires. Son traitement est calque sur celui des autres cancers du sein. Nos resultats rejoignent ceux de la litterature et confirment le pronostic favorable de cette forme histologique.

Resume Objectif Le traitement combine par radiochimiotherapie a ameliore le pronostic de la maladie de Hodgkin (MDH), mais a egalement augmente le risque de complications tardives, dont l'apparition de cancers secondaires. Notre etude retrospective a repertorie les cas de cancers du sein survenus apres traitement par radiotherapie et/ou chimiotherapie pour maladie de Hodgkin a l'institut Salah-Azaiz (ISA) de Tunis. Patients et methodes De 1975 a 2003, nous avons collige sept malades traites pour maladie de Hodgkin, ayant secondairement developpe un cancer du sein. Il s'agissait de six femmes et un homme dont l'âge moyen au diagnostic de la maladie de Hodgkin etait de 21 ans (12 a 29 ans). Le traitement avait comporte dans tous les cas une association radiotherapie et chimiotherapie essentiellement de type MOPP. L'irradiation sus- et sous-diaphragmatique a ete faite au cobalt, avec une dose moyenne de 41,3 Gy a raison de 2 Gy par fraction pour six malades et 3,3 GY pour un malade. Resultats Le delai moyen d'apparition du cancer du sein etait de 204 mois (123 a 276). L'âge moyen au diagnostic de la tumeur mammaire etait de 31 ans. La taille tumorale clinique moyenne etait de 47 mm (25–80 mm). La tumeur etait classee T2 dans deux cas, T3 dans un cas, T4b dans deux cas, et T4d dans les deux derniers cas. Il s'agissait de sept carcinomes canalaires infiltrants. Un envahissement ganglionnaire axillaire a ete note dans six cas. Tous les patients ont ete traites par mastectomie et chimiotherapie. Un seul a eu une radiotherapie limitee a la paroi thoracique a la dose de 45 Gy. La duree mediane de survie etait de 26,5 mois (12 a 48 mois). Quatre malades sont decedes et trois sont vivants avec un recul de 24, 31, et 144 mois. Discussion et conclusion Les cancers du sein representent 6,3 a 9 % des neoplasies secondaires apres traitement pour maladie de Hodgkin, motivant une surveillance senologique reguliere et precoce. Le traitement chirurgical reste classique. Cependant, la radiotherapie et la chimiotherapie sont modulees selon le traitement recu pour la maladie de Hodgkin.

Aim: To report epidemiologic and anatomoclinical transitions of inflammatory breast cancer ( IBC) in Tunisia. Materials and Methods: Data including clinico-pathological data for208 cases of T4d or PEV 3 non-metastatic breast cancer diagnosed between 2005 and 2010 were collected from patient records. Chi2 and Z tests were used to compare variables with two Tunisian historical series and a series about Arab-American patients. Results: Thirty three percent of our patients had their first child before 23 years of age and 56% had their menarche before 12 years, 75% never receiving oral contraception. Obesity was observed in 42% of women and IBC occurred during pregnancy in 13% of cases. Tumor grade was II-III in 90% of cases, HR was negative in 52%, HER2 was over expressed in 31% and invasion of more than 3 axillary nodes occurred in 18% of patients. We observed a pCR rate of 19% after neoadjuvant treatment (anthracyline-taxane used in 79%, trastuzumab in 27% ). Compared to historical Tunisian series (since 1996), IBC epidemiology remained stable in terms of median age, menopausal status and obesity. However we observed a significant decrease in median clinical tumor size and number of positive axillary lymph nodes. Comparison to IBC in Arab-Americans showed a significant difference in terms of median age, menopausal status, positivity of hormonal receptors and educational level. Conclusions: Our assessment of epidemiologic transition showed a reduction of clinco-pathological stage of IBC, keeping the same characteristics as compared to Tunisian historical series over a period of 14 years. Features seem to be different in Arab-American patients, probably related to migration, “occidentalization” of life style and improvement in socio-economic level

Schwannoma is a rare nervous tumor developed on schwan cells. Only 22 cases of breast schwannoma have been published since 2005. It usually appears as a breast lump having clinical and radiological characteristics suggestive of kindness. Its diagnosis is histological. Its treatment is surgical. Through two observations and a review of the literature we would try to remind the characteristics of this tumor.

Resume Objectifs. – Rappeler les particularites cliniques, morphologiques et histologiques de la tuberculose mammaire. Discuter les problemes diagnostiques cliniques et radiologiques poses par cette localisation, notamment dans le cadre du cancer du sein. Patientes et methodes. – Il s'agit d'une etude retrospective portant sur 65 femmes atteintes de tuberculose mammaire, diagnostiquee a l'institut Salah-Azaiez (centre de reference en matiere de cancer du sein) entre janvier 1980 et decembre 2001. Resultats. – Dans cette serie, la tuberculose mammaire represente 0,2 % de l'ensemble des localisations tuberculeuses declarees et 0,3 % des pathologies mammaires traitees a l'institut. L'âge moyen de nos patientes etait de 36 ans (19 a 79). Les tableaux cliniques etaient trompeurs. Dans 60 % des cas l'aspect etait celui d'une tumeur maligne, dans 24,6 % des cas celui d'un nodule benin et dans 16,4 % des cas celui d'un abces fluctuant. La mammographie a conclu a une lesion d'allure maligne dans 49 % des cas. La cytoponction realisee chez huit patientes est revenue blanche dans six cas et a ramene du caseum dans les deux autres. Le diagnostic a ete pose, pour toutes nos malades, apres etude anatomopathologique devant des lesions histologiques specifiques de la tuberculose sur des pieces de tumorectomie, ou de biopsie. Le diagnostic de tuberculose etant etabli, toutes les patientes ont beneficie d'un traitement medical antituberculeux dans un service de maladies infectieuses en dehors de l'institut. Discussion et conclusion. – Les tableaux cliniques et radiologiques de la tuberculose mammaire sont souvent trompeurs et posent un reel probleme de diagnostic avec les cancers du sein. Devant un tableau evocateur de tuberculose, des biopsies devront etre realisees afin d'eliminer un eventuel cancer.

Excellent local control rates can be achieved using multidisciplinary approach and combined surgical technics. Better vascular and nervous dissections, use of different flaps and isolated limb perfusion have been determinant. Resection's extent of retroperitoneal sarcoma is still debated, but compartmental surgery seems to achieve better local control. The impact of pre operative radiotherapy will be explored soon in a randomized EORTC trial. Concerning desmoids, authors address the question whether surgery and other aggressive treatments should systematically be part of first-line treatment, as growth arrest occurred in 2/3 of non-operated patients. The objective of on going biological studies is to use molecular findings to individualize the selection of management protocols. In the same way, surgical indications for gastrointestinal stromal tumors evolved: with the development of investigations, more micro-GIST are discovered, rising the question of wait and see policy for some of them. In locally advanced inoperable patients and metastatic patients, imatinib is the standard treatment. Secondary excision of residual disease has been shown to be related to a good prognosis in responding patients to imatinib, but it is still not demonstrated whether this is due to surgery itself or to a selection bias. An ongoing phase III EORTC randomises this secondary surgery after 6 to 12 months of imatinib in responding patients.

Inflammatory breast cancer (IBC) is characterized by a peculiar geographic distribution in incidence, being described as more common in Tunisia and the region of North Africa. The authors performed a systematic review of published literature on rapidly progressing breast cancer and IBC in Tunisia and analyzed the evolution in epidemiology, clinical presentation, treatment, and therapeutic results. They collected, analyzed, and compared all the indexed Tunisian articles about rapidly progressing breast cancer and IBC since the 1970s opening of the Institut Salah Azaiz Institute in Tunis. In the 1970s, rapidly progressing breast cancer diagnosis was based on the Poussee Evolutive classification (1-3). Since the 1990s, IBC diagnosis has been based on the American Joint Committee on Cancer Poussee Evolutive 3/T4d staging. The authors compared the historical data to the most recent publications in terms of epidemiology, clinical features, treatment, and therapeutic results. The most important historical report of rapidly progressing breast cancer concerned 340 patients, representing 58.5% of a cohort of 581 breast cancer patients collected from 1969 to 1974, including 320 (55.2%) with inflammatory signs, 37(6.5%) with Poussee Evolutive 2, and 283 (48.7%) with Poussee Evolutive 3. Subsequent papers have documented a steady decrease in incidence to the current 5% to 7% T4d/IBC. Since the 1970s, Poussee Evolutive in premenopausal woman has increased from 52.5% to 75%; rural predominance has persisted. The 5-year overall survival reached 28% by the year 2000. The authors' analysis demonstrated a trend of decreasing incidence of IBC diagnoses from 50% to presently

The treatment of soft tissue sarcomas of limbs should be discussed within an experienced multimodality team. Surgical resection remains the cornerstone of therapy for localized disease and achieves a five years overall survival around 75% and a local recurrence rate as low as 10% in the best series. In complex cases, neo-adjuvant treatments may be used such as systemic chemotherapy, isolated limb perfusion, or radiotherapy to achieve an optimal conservative approach. Molecular genetics of sarcomas and quality of margins are essential to guide diagnosis and therapeutic selection. In case of marginal or incomplete resection, a new enlarged surgical resection should always be discussed before administration of any adjuvant treatments. Many retrospective studies and two randomized studies (one of adjuvant brachytherapy and one of external beam radiotherapy) have shown that adjuvant radiotherapy after complete surgery significantly reduces the risk of local recurrence in extremity soft tissue sarcomas. A randomized study has compared pre- to postoperative radiotherapy. The results in terms of local control are similar in both arms. The risk of surgical complications is higher in the preoperative arm and the risk of late sequelae is higher in the postoperative arm. A randomized study within the French sarcoma group is ongoing evaluating the omission of postoperative radiotherapy in favourable cases. Presently, the role of systematic first-line invasive treatment (including surgery and/or radiotherapy) of desmoids is debated. It is becoming evident that up to 50% of patients with desmoids benefit from a front-line non-aggressive policy, because growth arrest is a common feature of this disease. Additional study of the molecular determinants of desmoid behaviour is needed to guide treatment.

Evaluation of surgical biopsy for mammary microcalcifications, in Tunisian patients according to the American College of Radiology's recommandations (ACR).[corrected] 100 patients treated in Salah Azaiez Institute from January 2005 to December 2006, who underwent surgical biopsy for breast microcalcifications The diagnosis was based on mammography associated in 60% of the cases, to ultra-sonography. We correlated biopsies results to ACR classification.123 surgical biopsies are related to ACR 3 lesions in 72 cases (58.5%) ACR 4 in 39 cases (32%) and ACR 5 in 14 case (11.5%). The histological examination showed malignant lesions in 4 cas/72 ACR3 (5.5%), 19/39 ACR4 (48.7%) and 10 among the ACR5 (71.4%).Our preliminary study introduces a diagnostic approach of mammary microcalcifications, that are usually infra-clinic lesions, in a general context of breast tumors detected with an average size of more than 3 cm.

Inflammatory breast cancer (IBC) is a clinical diagnosis characterized by a peculiar geographic distribution in incidence, being particularly common in Tunisia and the region of North Africa. The peculiar aspects of the disease in this region may provide some insights on the biological characteristics of the disease. We updated and revised the data from our single-institution experience using the more stringent diagnostic criteria of the International Union Against Cancer (UICC) based on the tumor-node-metastasis (TNM) classification. The new analysis included 419 newly diagnosed cases of IBC evaluated between 1975 and 1996 that were subdivided into three groups: group A (118 cases classified as T4d in 1990-1996); group B (175 cases reported as Pev 2 or 3 in 1975-81 and restaged as T4d); and group C (126 cases classified Pev 2 or 3 in 1975-81 and restaged as T4b). The frequency of IBC cases classified as T4d in the various series was 5.7% for group A (118/2,073) and 13.3% for group B (175/1,317), while T4b represented 9% for group C (126/1,317). The analysis demonstrated worse 5-year overall survival rates for groups A and B (8.5% and 11.3%, respectively) compared to group C (25.6%). Interestingly, using a more uniform classification criteria, the incidence of IBC was 5% to 7% compared to previous historical reports of up to 50% of newly diagnosed cases of breast cancer in Tunisia.

Typical medullary carcinoma of the breast is a rare histological form of breast carcinoma. It represents less than 5% of all breast cancer. It is known for its favourable prognosis. Considering the rarity of the series we could retrieve, we aimed at underlining the particularities of this pathology.Retrospective study about 33 cases of typical medullary carcinoma managed at the Salah-Azaïz Institute during a period of six years between 1994 and 1999.The mean age was 47.5 years. The left breast was concerned in about 55% of cases. Mean tumoral size was 46mm. Sixty-one percent of our patients were treated by radical surgery. Seventy-three percent undergo radiotherapy, 57% chemotherapy and 42% hormonotherapy. The five-year free-disease survival was about 85%.Typical medullary carcinoma of the breast is a rare histological form of breast carcinoma. Its treatment is similar to the other breast cancers. Our results agree with the different published studies and confirm its favourable prognosis.

Therapeutic results of Hodgkin disease (HD) have improved by the use of combined radio-chemotherapy. However, this association can increase the risk of on-term effects including secondary cancers. In a retrospective study, we collected secondary breast cancer (BC) in patients previously treated with chemoradiotherapy for Hodgkin disease at Salah-Azaïz institute of Tunis.Between 1975 and 2003, seven patients (six women and one man) treated for HD subsequently developed BC. Mean age at diagnosis of HD was 21 years (12-29). The first treatment was combined chemotherapy (MOPP-ABVD) and radiotherapy for all patients. Radiotherapy was delivered with cobalt 60 with large fields. The median dose was 41.3 Gy (2 Gy/fraction in 6 patients and 3.3 Gy in one).The breast tumours occurred after a median delay of 204 months (132-276). According to the TNM classification, we showed two stage T2, one stage T3, two stage T4b and two stage T4d. The mean clinical size was 47 mm (25-80 mm). All patients had infiltrating carcinoma. Axillary node histological involvement was found in 6 cases. All patients were treated by mastectomy and chemotherapy. Only one patient had a locoregional irradiation. Median survival was 26.5 months (12-48). Four patients died and three are still alive at respectively 24, 31 and 144 months.According to the previous data, breast cancer represents 6.3 to 9% of all second cancers occurring after HD treatment. We conclude that especially young women and girls treated for HD should be carefully monitored. We suggest that secondary BC be sometimes treated by conservative radiosurgical approach.

Schwannoma is a rare nervous tumor developed on schwan cells. Only 22 cases of breast schwannoma have been published since 2005. It usually appears as a breast lump having clinical and radiological characteristics suggestive of kindness. Its diagnosis is histological. Its treatment is surgical. Through two observations and a review of the literature we would try to remind the characteristics of this tumor.

Osler-Weber-Rendu disease is a hereditary vascular disease with multiple manifestations. The liver is involved rarely. Vascular abnormalities include telangiectasis and arteriovenous fistulas, sometimes associated with fibrosis and cirrhosis. Hepatic arteriovenous shunting may include secondary portal hypertension, reduced liver function and high cardiac output. Two cases of Osler-Weber-Rendu disease with extensive hepatic arteriovenous fistulation were described in detail and we report on their clinical features. In the first patient, treatment was symptomatic since liver transplantation is not indicated because the patient was asymptomatic. Embolization treatment of hepatic arteries was indicated in the second patient because he had biliary disease and recurrent cholangitis secondary to vasculo-biliary shunts. Therapy with arterial embolization, banding, or ligature of hepatic arteries is still limited and provides unsatisfactory long-term results. Liver transplantation offers now another therapeutic option for patients with intrahepatic high shunting and secondary pulmonary hypertension.

Remember the clinical, morphologic and histological particularities of mammary tuberculosis. Discuss clinical and radiological diagnostic problems caused by this localization, as far as breast cancer is concerned.This is a retrospective study concerning 65 women suffering from mammary tuberculosis, diagnosed at Salah Azaiez Institute between January 1980 and December 2001.In this series, mammary tuberculosis represents 0.2% of the declared tubercular localizations and 0.3% of the mammary pathologies treated at the institute. The mean age of our patients was 36 years (19 to 79). Clinical findings were misleading. In 60% of cases the aspect was of a malignant tumor, in 24.6% of cases of a benign nodule and in 16.4% of cases of an abscess. The mammography concluded to a malignant lesion in 49% of cases. The fine needle aspiration achieved at 8 patients was negative in 6 cases and brought back the caseum in the 2 others. The diagnosis has been made, for all our patients, after histological study when we found typical tuberculosis lesions on pieces of tumorectomy, or biopsy. The diagnosis of tuberculosis was established; all patients had an anti-tuberculosis medical treatment in a department of infectious diseases out of the institute.Clinical and radiological features of mammary tuberculosis are very confusing and cause a diagnostic problem with breast cancers. In front of symptoms evoking tuberculosis, biopsies must be done to eliminate an eventual cancer.

The fibrosarcomatous variant of dermatofibrosarcoma protuberans (DFSP) represents an uncommon form of DFSP which has a higher risk of local recurrence and distant metastases than ordinary DFSP. The aim of our study is to investigate clinicopathologic characteristics, treatment modalities and prognostic factors of nine cases of transformed DFSP admitted in Salah Azaiez Institute between 2002 and 2009. They were five men and four women. Median age at diagnosis was 52 years (35–87 years). The lesions were located on the abdominal wall (three cases), the upper limb (two cases), the back (two cases), the lower limb (one case) and the chest wall (one case). Tumor size ranged from 25 mm to 150 mm. After diagnosis, six patients were treated by wide local excision with margins ⩾2 cm, two patients had local excision without defined margins and one patient had incomplete local excision. Three patients underwent radiotherapy because of either cramped or unknown limits. Local recurrence was diagnosed in 5 cases and distant metastasis occurred in one patient. Fibrosarcomatous DFSP exhibits more aggressive behavior than DFSP. Their similar clinical presentation requires histopathological differentiation for prognosis. Treatment is based on wide local excision, radiation and targeted therapy.