Search

Lateral dog ear after mastectomy in overweight or large breasted patients is a source for patient discomfort and is aesthetically unpleasing. Although many different techniques have been proposed, none of them have emerged as standard. In 2012, the authors published their mastectomy technique based on an inverted L-scar incision and closure with a lateral skin flap advanced supero-medially onto the chest wall. Authors sought to report their experience with this technique in patients with wide or large breasts operated with mastectomy without immediate breast reconstruction. As a refinement to their initial technique, they added lipoaspiration to the lateral chest wall.A retrospective study identified 43 patients operated on using the L incision and lipoaspiration from January 2015 to January 2021. Patient and tumor characteristics, operative details, post-operative results, and complications were recorded. Patients were followed-up and assessed for arm motion restriction, lymphedema, and recurrence.The mean age was 68 years; the mean BMI was 29 kg/m 2. The mean follow-up was 32 months. The mean weight of the mastectomy specimen was 1009 g and the mean aspirated volume in the lateral chest wall was 450 mL. One patient had a hematoma, four patients had seroma, and one patient developed a minor wound dehiscence. No skin necrosis or arm movement restriction was observed. Two patients developed mild lymphedema. Three patients underwent delayed breast reconstruction.The proposed technique is a safe and effective method to avoid lateral dog deformity after mastectomy, achieving both functional and cosmetic outcomes.

Oncoplastic surgery (OPS) has extended the indications for breast-conserving surgery (BCS). Its role in patients with large breast cancers treated with neoadjuvant chemotherapy (NAC) is unclear. This study evaluated the oncological safety of OPS for tumors with partial response after NAC. A consecutive series of 65 patients who underwent OPS (study group) after NAC for large breast cancer from January 2004 to July 2018 was compared with 130 matched patients treated by NAC, followed by standard BCS in 65 cases and mastectomy in 65 cases (two case-controlled groups). The mean initial radiological tumor size was 46 mm. Residual pathological tumor size was 22 mm in the OPS cohort, 19 mm in the standard BCS cohort, and 31 mm in the mastectomy cohort (p > 0.05). The mean follow-up was 59 months in the study cohort. Five-year local recurrence rates were 0%, 0%, and 10.5% (0–22%) for the OPS, BCS, and mastectomy cohorts, respectively, while 5-year regional recurrence rates were 4.1% (0–11.1%), 0, and 19.4% (0–35.2%, p > 0.05), respectively. Five-year overall survival was 85.3% for the OPS cohort, 94.1% for the standard BCS cohort (p = 0.194), and 79.9% for the mastectomy cohort (p = 0.165). OPS is safe after NAC for large breast cancers, and provides excellent local control, identical to that of tumors with a better response, treated by standard BCS. After NAC, OPS can be a valuable treatment option for tumors that did not shrink optimally and would not be suitable for standard BCS.

Background There has over recent years been a constant increase in annual breast reconstruction figures. Although reports indicate that burns following breast reconstruction are a rare occurrence, there has nevertheless been a relative increase in cases. The key underlying causes of this type of condition remain unknown. Objectives The authors launched a new study on the demographic characteristics of burns in the breast reconstruction population with the inclusion of up-to-date data to assess cases and contributing factors. Methods The study was a multicenter retrospective review of patients who underwent any type of breast reconstruction and subsequently sustained burn injuries. Results Twenty-eight cases of burn injury following breast reconstruction were documented; 6 involved autologous flaps and 22 involved implants. Nine of the 10 implant exposure cases had previous history of radiotherapy, but there was no statistically significant difference between previous radiotherapy history and implant exposure (P = 0.32). Of the 13 cases sustaining full-thickness burns, a large number included implant-based reconstruction (n = 12, 92%), although no statistically significant difference was observed between type of reconstruction and incidence of full-thickness burns (P = 0.17). Conclusions Each patient undergoing breast reconstruction should be advised of the potential risks and instructed to avoid significant heat exposure and steer clear of dark-colored bathing suits. At the time of writing, this information has yet to be included in the vast majority of surgery-related informed consent documents. Level of Evidence: 4

The majority of patients undergoing bilateral prophylactic mastectomy request immediate implant-based breast reconstruction. Some patients, especially those with prior radiotherapy, are at increased risk of early cutaneous complications and implant loss. The authors developed the technique of primary fat grafting before delayed prophylactic mastectomy to minimize early complications for selective high-risk patients. They have completed 21 cases in 14 patients, 10 of whom had previous lumpectomy and radiation treatment for breast cancer. A single session of fat grafting, with a median injection volume of 250 ml (interquartile range, 200 to 300 ml), was performed a median period of 19 weeks (interquartile range, 16 to 28 weeks) before prophylactic mastectomy. All cases were direct-to-implant reconstruction using textured silicone implants. The median implant volume was 410 ml (interquartile range, 318 to 450 ml). A minor early complication developed in 14 percent of cases (three of 21), with no early implant loss. At a median follow-up of 9 months (interquartile range, 5 to 27 months), the authors found no cases of implant loss and an excellent or good aesthetic outcome (score of 5 or 4) in 16 of 21 cases (76 percent). Fat grafting before prophylactic mastectomy is a novel strategy to minimize early complications and avoid implant loss in patients at high risk of postoperative complications. .Therapeutic, IV.

Background/aim For women who have undergone a mastectomy, breast reconstruction provides psychological as well as aesthetic benefits. Thus, many patients ask for an immediate breast reconstruction (IBR). The present study focuses on risk factors assiociated with complications after IBR. Patients and methods A national prospective study (2007-2009) was conducted on 404 patients who underwent an unilateral IBR: 205 implants alone (IA) including 46 tissue expanders, 91 latissimus dorsi musculocutaneous flaps with implant (LDI), 78 autologous latissimus dorsi musculocutaneous flaps (LD), and 30 autologous transverse rectus abdominis musculocutaneous flaps (TRAM). Outcomes concerned major and minor complications, as well as early and late complications. Results Related risks of complications were different according to the IBR technique. Major complications rate remained moderate and concerned 15% of patients. Obesity and diabetes significantly increased the incidence of major complications. Conclusion To reduce complication rate, the risk factors associated with each type of IBR should be taken into account.

Oncoplastic surgery (OPS) has extended the indications for breast-conserving surgery (BCS). Its role in patients with large breast cancers treated with neoadjuvant chemotherapy (NAC) is unclear. This study evaluated the oncological safety of OPS for tumors with partial response after NAC.A consecutive series of 65 patients who underwent OPS (study group) after NAC for large breast cancer from January 2004 to July 2018 was compared with 130 matched patients treated by NAC, followed by standard BCS in 65 cases and mastectomy in 65 cases (two case-controlled groups).The mean initial radiological tumor size was 46 mm. Residual pathological tumor size was 22 mm in the OPS cohort, 19 mm in the standard BCS cohort, and 31 mm in the mastectomy cohort (p 0.05). The mean follow-up was 59 months in the study cohort. Five-year local recurrence rates were 0%, 0%, and 10.5% (0-22%) for the OPS, BCS, and mastectomy cohorts, respectively, while 5-year regional recurrence rates were 4.1% (0-11.1%), 0, and 19.4% (0-35.2%, p 0.05), respectively. Five-year overall survival was 85.3% for the OPS cohort, 94.1% for the standard BCS cohort (p = 0.194), and 79.9% for the mastectomy cohort (p = 0.165).OPS is safe after NAC for large breast cancers, and provides excellent local control, identical to that of tumors with a better response, treated by standard BCS. After NAC, OPS can be a valuable treatment option for tumors that did not shrink optimally and would not be suitable for standard BCS.

Introduction Breast cancer in women with cosmetic breast implants is increasingly common. Over the past decade, there has been a push for mastectomy and reconstruction in these patients, based on a fear of poor aesthetic results from small breast volume, and radiation-induced capsular contracture. At the Paris Breast Centre, augmented women routinely undergo lumpectomy with whole-breast irradiation (BCT). Materials and methods A consecutive cohort of 50 augmented women, who had attempted BCT for early breast cancer at our institution between 2003 and 2018, were retrospectively identified. Post-treatment complications, oncologic outcomes, capsular contracture rates, long-term cosmetic outcomes, and patient-reported outcomes were evaluated. Results The median follow-up was 51 months. Margins were involved in 7 women (14%); 4 of whom underwent successful re-excision, and 3 had a mastectomy, for an early mastectomy rate of 6%. There were no early complications, nor cases of early implant loss. Long-term aesthetic results were evaluated using our 5-point scale: An excellent (5), or good (4) result was obtained in 68%. Significant capsular contracture (Baker grade 3 or 4) developed in 34%, of which, 5 women underwent capsulotomy and fat grafting; 4 of 5 downstaging their Baker grade. The estimated 5-year local recurrence rate was 2.3%. Ninety-five percent of participants would recommend BCT to augmented women. Conclusion BCT is feasible and safe in augmented women with good long-term aesthetic results, and should be considered to avoid unnecessary mastectomy.

Summary Background Breast implants are widely used in reconstruction after breast cancer. Infection after implant reconstruction is a major complication, with rates ranging from 5 to 30%. This rate is less for pure cosmetic augmentation. Historically, infection of an implant mandated implant removal for sepsis control. An alternative is to attempt to salvage the infected implant. This path can be a long one, requiring surgery for washouts and prolonged antibiotic therapy. This article documents our experience of infected implant salvage over the last 13 years. Methods We conducted a retrospective analysis of all patients who developed a breast implant infection between January 2005 and January 2018. All patients had both clinical signs of infection and a positive bacteriological sample. Patients were divided into two groups: upfront medical therapy (including those requiring secondary surgical salvage) and primary surgery. The salvage procedure was defined as successful when the implant was still in place three months after the initial reconstruction. Results Eighty patients were included: 77 in the medical group and 3 in the surgical group. Overall, implant salvage was achieved in 88.8% of women (n=71). Of these, 73.8% (n=59) underwent medical treatment alone and 15% (n=12) underwent medical treatment followed by surgical management. The main causative organism was staphylococcus in 81.2%. When the infection was caused by a coagulase-negative staphylococcus, the rate of success was 98% (p Conclusions This case series reports that salvage of an infected breast implant was achievable in up to 90% of women presenting with a documented infection, the majority requiring antibiotic management only. Early intervention is central to success.

Two thirds of node-positive breast cancer patients have limited pN1 disease and could benefit from a less extensive axillary lymph node dissection (ALND).172 breast cancers patients requiring an ALND were prospectively enrolled in the Sentibras Protocol of Axillary Reverse Mapping (ARM). Radioisotope was injected in the ipsilateral hand the day before surgery. ALND was standard. Removed lymph nodes were classified into non radioactive nodes and radioactive nodes (ARM nodes). Among ARM nodes, nodes located in the upper outer part of the axilla, above the second intercostal brachial nerve and lateral to the lateral thoracic vein were identified as "zone D ARM nodes". The main objective was: feasibility of identification of the zone D ARM nodes. Secondary objectives were: metastatic involvement and lymphedema rate.100% of patients had ARM nodes identified. The "zone D ARM nodes" were identified in 92% of cases. The rate of metastatic nodes was 60% in the all cohort, 31% in ARM nodes and 9% in zone D ARM nodes. Among those, metastatic rate was 6% in patients undergoing ALND for a positive sentinel node biopsy, 6% in case of primary ALND versus 14% after neo-adjuvant chemotherapy (p 0.05). After 34 months of median follow up, 27% of interviewed patients had a lymphedema.The ARM technique reliably identifies the "zone D ARM nodes". These nodes can also easily be identified using knowledge of axillary anatomy. In selected patients, a selective ALND sparing the zone D ARM nodes could be performed.

Oncoplastic surgery (OPS) allows wider resections with immediate breast reshaping by mammoplasty. This study reviews our experience with level 2 mammoplasties in patients with histology-proven pure ductal carcinoma in situ (DCIS).From a prospectively maintained database of 392 consecutive oncoplastic level 2 mammoplasties, 68 patients presented with pure DCIS. Involved margin rates and locoregional recurrence rates were calculated, with 76 months (0-166 months) median follow-up.The mean pathological tumor size was 34 mm (median 26 mm, range 2-106 mm). The mean resection weight was 191 g (median 131 g, range 40-1150 g). Margins were clear in 58 cases (85.3%) and involved in 10 cases (14.7%). Margins were involved in 1 out of 54 (1.9%) cases with tumor size under 50 mm and in 9 out of 14 (64.3%) cases with tumor size higher than 50 mm (p 0.001). On multivariable analysis, only tumor size 50 mm [odds ratio (OR) 95.400; p 0.001] was independently associated with involved margins. Seven patients had mastectomy. The overall breast conservation rate was 89.4%, and 100% for tumors less than 5 cm. There were three local recurrences. The 5-year cumulative incidence for local recurrence was 5.5% (0-11.5%).OPS is a safe solution for large DCIS up to 50 mm, with an involved margin rate of only 1.9%, and can thus reduce the mastectomy rate in this group. As margin involvement significantly increases for tumors larger than 5 cm, better preoperative localization and/or wider excisions are necessary in this group.

Oncoplastic techniques applied to breast-conserving surgery (BCS) allow large-volume resections without compromising cosmetic results. Level II oncoplastic techniques are based on mammoplasties. When required, they allow resection of more than 20 % of the breast volume; however, a subgroup of these patients will still have positive margins. The clinical management of positive margins after level II oncoplastic surgery (OPS) is a challenge.All patients who had undergone level II oncoplastic techniques at The Paris Breast Center between 2004 and 2013 were reviewed. The choice of the optimal mammoplasty technique was based on the tumor location and the 'quadrant per quadrant atlas'.A total of 277 level II oncoplastic techniques were performed on 272 patients. The mean tumor size was 26 mm (range 2-160 mm), with a mean resected weight of 175 g (range 50-1540 g). The rate of positive margins was 11.9 %. Risk factors for positive margins identified in univariate analysis were histologic subgroup, tumor size, T stage and grade. In multivariate analysis, only patients with invasive lobular carcinoma had a significantly higher risk of positive margins. A second operation was required in 33 cases, and a third operation was required in three cases because of positive margins. Final breast conservation rate was 91 %.Level II OPS results in a low positive margin rate despite large tumor size. Patients with involved margins can be offered a second BCS if the remaining volume allows this.

In recent decades, the surgical management of breast cancer has steadily and considerably improved. Mutilating procedures have given way to more individualized surgical approaches aiming to preserve the breast as much as possible. For large tumors, preoperative chemotherapy is a major tool, but emerging oncoplastic surgery techniques are also a new approach in the armamentarium of breast cancer surgery, as a third option between conventional breast-conserving surgery and mastectomy. As this new treatment modality allows wider margin excision, it reduces the need for re-excision procedures and possibly increases breast conservation rates by extending the indications of breast-conserving surgery. This review will provide an overview of current practices and clinical data available to date on oncoplastic surgery.

The aim of this study was to evaluate the long-term oncologic outcome after oncoplastic surgery (OPS).OPS combines wide tumor excision with reduction mammoplasty techniques thus extending breast conserving surgery to large tumors that might else be proposed a mastectomy. Little data are available about the oncologic results for breast conserving surgery of these larger tumors.From January 2004 until March 2016, a total of 350 oncoplastic breast reductions were prospectively entered into a database. Patients were included if their breast reshaping included a reduction mammoplasty with skin excision (Level 2 oncoplastic techniques).Histologic subtypes were: invasive ductal carcinoma in 219 cases (62.6%), ductal carcinoma in situ (DCIS) in 88 cases (25.1%), and invasive lobular carcinoma in 43 (12.3%) cases. Seventy-three of the invasive cancers (27.9%) received neoadjuvant chemotherapy. The mean resection weight was 177 grams. The mean pathological tumor size was 26 mm (range 0-180 mm) and varied from 23 mm (4-180 mm) for invasive cancers to 32 mm (0-100 mm) for DCIS. Specimen margins were involved in 12.6% of the cases; 10.5% of invasive ductal, 14.7% of DCIS, and 20.9% of invasive lobular. The overall breast conservation rate was 92% and varied from 87.4% for DCIS to 93.5% for the invasive cancers. Thirty-one patients (8.9%) developed one or more postoperative complications, inducing a delay in postoperative treatments in 4.6% of patients. The median follow up was 55 months. The cumulative 5-year incidences for local, regional, and distant recurrences were 2.2%, 1.1%, and 12.4%, respectively.Oncoplastic breast reductions allow wide resections with free margins and can be used for large cancers as an alternative to mastectomy.

Summary Background Fat grafting is an efficient method to correct large volumetric defects after mastectomy. There is an ongoing debate regarding the best method of processing the harvested fat before fat grafting. This study aimed to introduce a new MRI model and to compare two fat processing techniques measuring the gain in soft tissue thickness after fat grafting to the chest wall. Methods Fifty-one mastectomy patients (one double sided), who required delayed implant reconstruction, with poor skin conditions were proposed fat grafting prior to implant reconstruction. At the time of fat grafting, patients were randomly assigned to centrifugation or sedimentation of the aspirated fat. The trial was undertaken in a single-center private practice setting. The gain in soft tissue thickness of the chest wall was measured using an MRI model, with 12 predefined points for measurement. Two MRIs were performed, one prior to fat grafting and one 8 weeks thereafter. The radiologist was blinded to the fat graft processing method used. Results Seven cases were excluded because they did not complete their second MRI. The analyses were thus based on 44 patients (one double sided). Centrifugation was performed in 21 cases and sedimentation in 24 cases. The mean gain in soft tissue thickness was +7.0 mm in the centrifugation group and +8.8 mm in the sedimentation group (p = .268). The mean operative time was 88 min in the centrifugation group and 78 min in the sedimentation group (p = .11). There were no adverse events for any of the patients. Conclusions We developed a simple and reproducible MRI model to objectively measure and evaluate different fat processing techniques prior to fat grafting. At a median time of 8 weeks after one session of fat grafting, there was no benefit of centrifugation over sedimentation.

Oncoplastic surgical techniques offer an option of breast conserving surgery for larger tumors with the use of glandular reshaping to prevent postoperative deformity. A technique for the excision of lower inner quadrant tumors via a V incision is described, the lower-inner quadrant-V (LIQ-V) mammoplasty, and the results of a pilot study are reported. Retrospective collection of pre- and postoperative data was collected from patients undergoing a LIQ-V mammoplasty for a LIQ tumor. Twenty-two patients were operated on between 2004 and 2011 at a mean age of 58 years. The mean follow-up was 55 months. The mean resection weight was 101 g for tumors ranging in size from 4 to 31 mm. The margins were clear in 95 % of cases. There was one case of local recurrence and metastatic disease. The cosmetic outcome was judged as excellent in 68 % of cases, and no patient required further ipsilateral or contralateral symmetrizing surgery. The deformity often associated with tumors of the LIQ is adequately addressed by this new technique. It has a complication rate comparable to other mammoplasty series and a high rate of clear resection margins. Many oncoplastic surgery techniques are based on inverted T mammoplasty, but these are not suited for all tumor locations. The LIQ-V mammoplasty is an adaptation of the standard techniques that best suit the LIQ. It is oncologically safe and provides disease-free margins, and although the resection volumes are large, the cosmetic outcome is not compromised.

Resume Introduction La reconstruction mammaire apres mastectomie et radiotherapie repose preferentiellement sur la realisation d’un lambeau. La reconstruction par implant seul est, dans ces cas particuliers, grevee d’un taux eleve de complications et de resultats cosmetiques peu satisfaisants. La demonstration des proprietes regeneratives du transfert graisseux nous a conduit a mener une etude prospective visant a etudier l’effet du lipofilling prealable de la paroi thoracique irradiee avant reconstruction prothetique. Patientes et methodes Les patientes ont ete incluses de 2007 a 2011. Toutes ces patientes avaient eu une mastectomie et une irradiation parietale. Une ou plusieurs seances de lipofilling ont ete realisees prealablement a la reconstruction mammaire par implant. Les patientes ont ete suivies afin de recueillir les donnees suivantes : complications postoperatoires ; resultat cosmetique evalue, en utilisant une echelle numerique de 1 a 5 (1 : mauvais ; 5 : tres bon), par deux chirurgiens de l’equipe, une assistante medicale et la patiente ; recidives tumorales. Resultats Soixante-huit patientes ont ete incluses. Le nombre moyen de seances avant pose de l’implant etait de 2,3 (une a six seances). Le volume moyen de graisse injectee par seance etait de 115 cm3 (70–275). Le volume moyen des implants etait de 300 mL (185–400 mL). La duree moyenne du suivi est de 23 mois (quatre a 50 mois). Aucune recidive tumorale locale n’a ete diagnostiquee. Il n’y a eu aucune complication liee au lipofilling. Le taux d’explantation d’implant est de 1,47 % (1/68). Le score cosmetique moyen est de 4,5 (3,5–5). Conclusion La reconstruction mammaire differee par prothese avec lipofilling(s) prealable(s) peut etre une alternative a la reconstruction par lambeau chez les patientes apres mastectomie et irradiation de la paroi thoracique.

Background The majority of published techniques for oncoplastic surgery rely on an inverted-T mammoplasty, independent of tumour location. These techniques, although useful, cannot be adapted to all situations. A quadrant-per-quadrant atlas of mammoplasty techniques for large breast cancers was developed in order to offer breast surgeons a technique dependent on tumour location, which reduces the risk of postoperative complications and delay to adjuvant therapy. Methods From 2005 to 2010, a series of eligible women with breast cancer were treated by quadrant-specific oncoplastic techniques. All complications and any delay to adjuvant treatment were recorded prospectively, along with local and distant cancer recurrences. Cosmetic outcome was evaluated using a five-point scale. Results A total of 175 patients were analysed. The median tumour size, after histological examination, was 25 (range 4–90) mm. Twenty-three patients (13·1 per cent) had involved margins. Seventeen of these patients were treated by mastectomy and three had a re-excision. Complications occurred in 13 patients (7·4 per cent), which led to a delay to adjuvant treatment in three (1·7 per cent). After a median follow-up of 49 (range 23–96) months, three patients had developed a local recurrence. The mean score after cosmetic evaluation was 4·6 of 5. Conclusion A quadrant-per-quadrant approach to oncoplastic techniques for breast cancer was developed that tailors the mammoplasty for each tumour location. This panel of techniques should be a useful guide for breast surgeons, and extends the possibilities for breast conservation for large or poorly limited cancers, with a low complication rate and good cosmetic results.

Background Conservative treatment of lower pole breast cancer in small or medium sized breasts could be attended with poor cosmetic outcomes. The purpose of this study was to assess the results of the “Crescent” Oncoplastic technique in this indication. Material and methods Prospective study in 54 breast cancer patients undergoing the technique. Results Post-operative recovery was uneventful except 1 hematoma and 6 breast seromas. With a mean follow-up period of 45 months (range 27–64), no local recurrence s was detected. Five patients had fat necrosis. Cosmetic results were assessed as being excellent (39%), good (35%), fair (20%) and mediocre (6%). Conclusion We therefore advise this technique as a first step oncoplastic surgery technique for tumors situated near the inframammary fold. We also recommend the systematic check of the final cosmetic results in the standing position in order to obtain the best possible results.

Clinicians can use biomarkers to guide therapeutic decisions in estrogen receptor positive (ER+) breast cancer. One such biomarker is cellular proliferation as evaluated by Ki-67. This biomarker has been extensively studied and is easily assayed by histopathologists but it is not currently accepted as a standard. This review focuses on its prognostic and predictive value, and on methodological considerations for its measurement and the cut-points used for treatment decision. Data describing study design, patients’ characteristics, methods used and results were extracted from papers published between January 1990 and July 2010. In addition, the studies were assessed using the REMARK tool. Ki-67 is an independent prognostic factor for disease-free survival (HR 1.05–1.72) in multivariate analyses studies using samples from randomized clinical trials with secondary central analysis of the biomarker. The level of evidence (LOE) was judged to be I-B with the recently revised definition of Simon. However, standardization of the techniques and scoring methods are needed for the integration of this biomarker in everyday practice. Ki-67 was not found to be predictive for long-term follow-up after chemotherapy. Nevertheless, high KI-67 was found to be associated with immediate pathological complete response in the neoadjuvant setting, with an LOE of II-B. The REMARK score improved over time (with a range of 6–13/20 vs. 10–18/20, before and after 2005, respectively). KI-67 could be considered as a prognostic biomarker for therapeutic decision. It is assessed with a simple assay that could be standardized. However, international guidelines are needed for routine clinical use.

International audience; The purpose of this prospective multicenter study was to assess one-step nucleic acid amplification (OSNA) for intraoperative sentinel lymph node (SLN) metastasis detection in breast cancer patients, using final histology as the reference standard. OSNA results were also compared to intraoperative histology SLN evaluation and to standard clinicopathological risk markers. For this study, fresh SLNs were cut in four blocks, and alternate blocks were used for OSNA and histology. CK19 mRNA copy number was categorized as strongly positive, positive, or negative. Positive histology was defined as presence of macrometastasis or micrometastasis. When discrepancies occurred, the entire SLNs were subjected to histological studies and the node lysates to additional molecular studies. Five hundred and three SLN samples from 233 patients were studied. Mean time to evaluate two SLNs was 40 minutes. Sensitivity per patient was 91.4% (95%CI, 76.9%-98.2%), specificity 93.3% (95%CI, 88.6%-96.6%), positive likelihood ratio 13.7, and negative likelihood ratio 0.1. Sensitivity was 63.6% for frozen sections and 47.1% for touch imprint cytology. Both methods were 100% specific. Positive histology and positive OSNA were significantly associated with highest clinical stage, N1 status, and vascular invasion; and OSNA results correlated with HER2/neu status and benefited patients with negative histology. These findings show that OSNA assay can allow detection of SLN metastasis in breast cancer patients intra-operatively with a good sensitivity thus minimizing the need for second surgeries for axillary lymph node detection.

Lipofilling is now performed to improve the breast contour, after both breast-conserving surgery and breast reconstruction. However, injection of fat into a previous tumor site may create a new environment for cancer and adjacent cells. There is also no international agreement regarding lipofilling after breast cancer treatment.The authors included three institutions specializing in both breast cancer treatment and breast reconstruction (European Institute of Oncology, Milan, Italy; Paris Breast Center, Paris, France; and Leon Berard Centre, Lyon, France) for a multicenter study. A collective chart review of all lipofilling procedures after breast cancer treatment was performed.From 2000 to 2010, the authors reviewed 646 lipofilling procedures from 513 patients. There were 370 mastectomy patients and 143 breast-conserving surgery patients. There were 405 patients (78.9 percent) with invasive carcinoma and 108 (21.1 percent) with carcinoma in situ. The average interval between oncologic surgical interventions and lipofilling was 39.7 months. Average follow-up after lipofilling was 19.2 months. The authors observed a complication rate of 2.8 percent (liponecrosis, 2.0 percent). Twelve radiologic images appeared after lipofilling in 119 breast-conserving surgery cases (10.1 percent). The overall oncologic event rate was 5.6 percent (3.6 percent per year). The locoregional event rate was 2.4 percent (1.5 percent per year).Lipofilling after breast cancer treatment leads to a low complication rate and does not affect radiologic follow-up after breast-conserving surgery. A prospective clinical registry including high-volume multicenter data with a long follow-up is warranted to demonstrate the oncologic safety. Until then, lipofilling should be performed in experienced hands, and a cautious oncologic follow-up protocol is advised.Therapeutic, IV [corrected].

Background The main goal of breast conservative surgery (BCS) is the complete removal of cancer with clear margins and no deformity of the breast. However, in invasive lobular carcinoma (ILC) this goal is hard to achieve because of the underestimation of tumor size. Our study was the first to show the role of surgical techniques in the achievement of clear margins for ILC. Methods We reviewed 73 patients with ILC who underwent BCS at Paris Breast Center between January 2005 and June 2008. Full thickness excision (FTE) was performed in a routine basis and oncoplastic surgery (OPS) upon tumor location, volume ratio and overall density of the breast. Margin status was evaluated as positive, close or clear. Results Positive/close margins were found in 39% of cases and were lower than what was described in the literature (49–63%). FTE was performed in 47 (64%) patients and OPS in 26 (36%) patients. No positive/close margins were observed in patients with lesions located in the lower/central quadrants. Multivariate analysis showed multifocality, larger tumor size and FTE to be independent risk factors for positive margins at final surgery. Conclusions Our rate of positive/close margins for ILC was lower than what was described in the literature. The determinant key difference was in our surgical procedures with FTE or OPS differing from the standard BCS described in the literature and we suggest that OPS is to be considered for ILC. It allows larger breast conservative surgery with good cosmetic results and lower rate of compromised margins.

OBJECTIVE Oncoplastic Surgery is an evolving field in breast cancer surgery. Considerable variations in oncoplastic surgery (OPS) for breast conservation (BCS) have developed as the interest and utilization by both breast surgeons and plastic surgery teams continues to increase. Our goal is to assess the effectiveness of an oncoplastic surgical planning tool for BCS. The tool is a surgical atlas and guide that matches oncoplastic procedure recommendations for a specific tumor location. BACKGROUND Oncoplastic surgery for the treatment of breast cancer has been validated compared to standard BCS in terms of rate of re-excision, preservation of the natural breast shape, complications and 5-year local recurrence rates. Oncoplastic surgery incorporates plastic surgery techniques for the purpose of breast conservation. A bi-level OPS classification system and guide for patient selection was created to improve both patient outcomes and enable all breast surgeons to choose a safe and effective oncoplastic approach. METHODS This is a single institution prospective study of patients with breast cancer that had an oncoplastic level II procedure for breast conservation between 2005 and 2009 at the Paris Breast Center. The corresponding level II OPS technique was chosen for each patient based on the principals of patient selection and tumor location described in the atlas. A set of objective outcomes as well as an aesthetic evaluation was recorded based on tumor location and choice of procedure. Results A total of 151 patients met the criteria for performing a level II OPS for breast conservation based on the selection process outlined in the oncoplastic Atlas. The overall adherence rate for selection of procedure based on tumor location was 90%. The reexcision rate was 4% with greater then 80% of patients achieving a margin width exceeding .5cm and an average specimen weight of 144 grams. The conversion rate to mastectomy approached 12%. We found a good to excellent aesthetic outcome in 95% of evaluated patients. The rate of deformity in this level II OPS series was 0%. The early complication rate was 11% resulting in a delay of treatment for adjuvant therapy in less then 2% of patients. Tumor Location and OPS Level II Procedure Complications and Delay in Treatment CONCLUSIONS Adherence to the oncoplastic surgical guide resulted in an acceptable reexcision rate with the elimination of the risk of deformity for patients undergoing large volume resections for breast conservation. This initial assessment validates the efficacy of the atlas and provide surgeons with a reliable system to correctly choose the most appropriate oncoplastic procedure based on tumor location and avoids the complications associated with a one technique fits all approach for OPS. Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P4-10-09.

Oncoplastic surgery (OPS) has emerged as a new approach for extending breast conserving surgery (BCS) possibilities, reducing both mastectomy and re-excision rates, while avoiding breast deformities. OPS is based upon the integration of plastic surgery techniques for immediate reshaping after wide excision for breast cancer. A simple guide for choosing the appropriate OPS procedure is not available. To develop an Atlas and guideline for oncoplastic surgery (OPS) to help in patient selection and choice of optimal surgical procedure for breast cancer patients undergoing BCS. We stratify OPS into two levels based on excision volume and the complexity of the reshaping technique. For resections less than 20% of the breast volume (level I OPS), a step-by-step approach allows easy reshaping of the breast. For larger resections (level II OPS), a mammoplasty technique is required. We identified three elements that can be used for patient selection and for determination of the appropriate OPS technique: excision volume, tumor location, and glandular density. For level II techniques, we defined a quadrant per quadrant Atlas that offers a different mammoplasty for each quadrant of the breast. OPS is the “third pathway” between standard BCS and mastectomy. The OPS classification and Atlas improves patient selection and allows a uniform approach for surgeons. It proposes a specific solution for different scenarios and helps improve breast conservation outcomes.

A consensus conference including 30 experts was held in April, 2007, to discuss risk factors for breast cancer and their management. Four categories of risk were outlined, from "average" through "very high" risk, the latter including individuals with high penetrance BRCA1/2 gene mutations. Guidelines for management of patients in each of these categories were discussed, with the major portion of the conference devoted to individuals with BRCA1/2 mutations. Prevalence of these mutations in the general population was estimated to be 1 in 250-500 individuals, with an increased prevalence in Ashkenazi Jews and other founder groups. Risk-reduction strategies for these individuals included surveillance, with or without chemoprevention drugs, or surgical procedures to remove the organs at risk, ie, bilateral mastectomy and/or bilateral salpingo-oophorectomy. These risk reduction strategies were evaluated fully, and recommendations were made for the care of patients in each risk category. These guidelines for patient care were approved by the entire group of experts.

Resume En cas de cancer du sein, 60 a 75 % des patientes ont un traitement conservateur. Celui-ci peut laisser des sequelles esthetiques qui amenent la patiente a demander une reconstruction du sein traite. Ces demandes de reconstruction partielle sont de plus en plus frequentes et constituent un probleme difficile pour le chirurgien plasticien. Nous avons defini et publie une classification des sequelles esthetiques du traitement conservateur (SETC). Cette classification en trois types permet de decrire ces sequelles variees et parfois complexes, mais surtout de guider leur traitement. Nos publications initiales portaient sur 35, puis 85 patientes : nous avons actuellement opere plus de 150 patientes pour SETC. Les sequelles de type 1 sont definies par une asymetrie mammaire iatrogene, sans deformation. Les sequelles sont de type 2 s’il existe une deformation evidente du sein traite accessible a une reconstruction partielle du sein et de type 3 si cette deformation est telle que seule une mastectomie avec reconstruction totale est envisageable. La majorite des consultations porte sur des sequelles de type 2, mais certaines patientes sont reticentes a une chirurgie jugee trop lourde. Dans une serie prospective de 85 patientes operees pour SETC, les sequelles etaient de type 1 chez 48 patientes (56,5 %), de type 2 chez 33 (38,8 %) et de type 3 chez quatre (4,7 %). Les SETC de type 1 sont traitees essentiellement par plastie mammaire controlaterale, pour corriger l’asymetrie. Il faut limiter la chirurgie du cote irradie : une mise en place de prothese ou une plastie mammaire sont a haut risque de complication apres radiotherapie. Les SETC de type 2 sont les plus difficiles a traiter et font intervenir toutes les techniques de chirurgie plastique du sein. Le recours a un lambeau musculocutane (LMC) est souvent necessaire. Le lipofiling semble une voie de recherche prometteuse dans certains deficits localises. Toutefois, le developpement doit se faire en amont, en developpant les techniques de chirurgie oncoplastique lors du temps initial d’exerese tumorale. Les SETC de type 3 sont rares et necessitent une mastectomie avec reconstruction immediate par LMC. Nous confirmons la validite de la classification des SETC : il s’agit d’un guide simple et pratique pour les chirurgiens prenant en charge ces patientes.

Despite the widespread use of the sentinel lymph node biopsy technique, many patients with invasive breast cancer still undergo an axillary lymph node dissection and are at risk of arm lymphedema. With the new awareness of lymphatic spread in the axillary nodes, it should be possible to define a new surgical approach between sentinel lymph node biopsy and complete axillary dissection, a procedure preserving specifically lymph nodes in relation to the arm. Twenty-one patients with an operable breast cancer requiring an axillary dissection underwent surgery with an attempt to separate nodes related to the breast from specific nodes related to the arm. After an injection of blue dye in the arm, the surgeon performed the axillary dissection trying to identify blue nodes and ducts in order to preserve lymphatic arm drainage (LAD). If the blue nodes were located in the normal axillary dissection, they were removed separately. In 15 of 21 patients (71%), blue nodes in relation with LAD were identified. In 10 (47%) patients, it was possible to dissect the LAD with the preservation lymphatic ducts. In 10 patients, the LAD nodes were removed: none of them contained metastases, despite the fact that the non-LAD axillary nodes contained metastases in 7 of 10 cases. Identifying the LAD with blue dye injection in the arm is possible. A subsequent study can now begin to determine if this procedure is safe for patients and able to prevent lymphedema of the arm.

Lipotransfer represents a technical revolution in plastic surgery and is increasingly used worldwide. Although known for several decades, lipofilling has only recently found widespread use in patients with breast cancer to improve the results of breast reconstructions and to correct deformities after conservative treatment. The plastic surgery literature underlines the technique's versatility and the quality of the results, showing lipofilling as an effective cosmetic procedure and proposing it as a safe, neutral biological material that is able to restore the body contour. Several studies underline the power of transferred fat to regenerate blood supply in skin disorders following radiotherapy.

International audience; Women who have undergone surgical treatment for breast cancer often benefit from a contralateral reduction mammaplasty (CRM) aimed at symmetrization of the contralateral breast unaffected by the initial cancer. In our 7-year multicentric study (12 centers) of 2718 patients, incidence of CRM cancers (CRMc) was 1.47% (n = 40) [95% CI 1.05%-2.00%]. The CRMc group had significantly more initial mammary cancers of invasive lobular carcinoma (ILC, 22.5% vs 12.0%) and ductal carcinoma in situ (DCIS, 35.0% vs 21.6%) types than the healthy CRM group (p = 0.017). 35.0% (n = 14) of patients had en bloc resection; 25.0% (n = 10) of surgical specimens were correctly oriented. En bloc resection and orientation of surgical specimens enable precise pinpointing of the CRMc. A salvage lumpectomy may be proposed as an option when margins are invaded. The histological distribution of the 40 CRMc (mean size 12.7 mm) was carcinoma in situ (CIS) 70%, ILC 12.5%, invasive ductal carcinoma (IDC) 12.5% and tubular carcinoma (TC) 5.0%.

ordon F Schwartz, MD, MBA, FACS, Umberto Veronesi, MD, FACS(Hon), Krishna B Clough, MD, Michael Dixon, MB, ChB, FRCS(Eng), FRCS(Edin), Ian S Fentiman, MD, DSc, ylvia H Heywang-Kobrunner, MD, Roland Holland, MD, PhD, Kevin S Hughes, MD, FACS, obert E Mansel, MB, MS, FRCS, Richard Margolese, MD, Ellen B Mendelson, MD, vo A Olivotto, MD, FRCPC, Juan P Palazzo, MD, Lawrence J Solin, MD, he Consensus Conference Committee*

The current retrospective study was intended to obtain up-to-date and comprehensive data on surgical practice for breast cancer throughout France, including neoadjuvant chemotherapy (NAC) and the more recent surgical techniques of oncoplastic surgery (OPS). In June 2011, e-mail surveys were sent to 33 nationally renowned breast cancer surgeons from French public or private hospitals. The questionnaire focused on all the new cases of breast cancer treated in 2010. It included questions regarding surgical practices, with special emphases on NAC and OPS and other surgical characteristics. The overall response rate for the survey was 72.7 %. The total number of breast cancer cases from the survey was 13,762, which constitutes 26.2 % of the total incidence in 2010. Breast-conserving surgery (BCS) was performed for 71.0 % of the patients, and the results were similar throughout the types of practices. Of these patients, 13.9 % received OPS, either upfront or after NAC. Mastectomy was performed for 29.0 % of the patients, which is consistent with French official numbers. Among all patients, 16.3 % underwent surgery after NAC. To the authors’ knowledge, there are no publications of national figures on NAC or OPS rates to date. They are convinced that this study offers real-life surgical care information on a large population and covers France’s breast cancer surgical landscape. Mastectomy rates in France remain stable and consistent with those in other European countries. However, additional large-scale retrospective studies are required to confirm these figures and further explore NAC and OPS rates as well as surgical practice characteristics.

Resume Objectif. – Les resultats esthetiques tardifs des reconstructions mammaires par prothese (RMP) ont fait l'objet de peu de publications. Cette etude prospective a ete initiee en 1990 avec trois objectifs : evaluer les resultats esthetiques et les complications tardives des RM par prothese, quantifier l'evolution du resultat esthetique de la RMP avec le temps ; et analyser les facteurs predictifs des mauvais resultats esthetiques. Materiels et methodes. – Cette etude porte sur 360 RM immediates par protheses realisees consecutivement entre 1990 et 1997. Vingt-huit patientes ont eu une irradiation parietale : elles ont ete exclues de cette serie. La reconstruction a fait appel a une prothese fixe (57,2 %) ou d'expansion (42,8 %). Le sein controlateral a ete symetrise dans le meme temps operatoire, mais un deuxieme temps sous anesthesie locale ou generale a toujours ete necessaire pour terminer la RM. Toutes les patientes ont ete reconvoquees systematiquement : elles ont ete revues au moins une fois par an, et evaluees prospectivement. Les eventuelles complications ont ete notees, et le resultat esthetique de la RMP a ete quantifie selon une echelle predefinie et enregistre dans une base de donnees specifiquement construite pour cette etude. Resultats. – Le suivi moyen etait de 4,2 ans avec un suivi maximum de dix ans. Le taux de coques (Baker 3 et 4) etait de 11 % a deux ans et 15 % a cinq ans ; la grande majorite des coques survenait dans les deux premieres annees. Le taux de degonflage etait de 2,7 % a deux ans et 8,5 % a cinq ans. Les resultats esthetiques ont ete evalues selon une echelle de 1 a 5 (1 = TB, 2 = B…, 5 = Mauvais). Le taux de resultats satisfaisants (TB, B, AB) etait de 85 % a un an, et a diminue de facon lineaire pour atteindre 52 % a cinq ans. Aucun des parametres suivants : technique de reconstruction (prothese vs expandeur), type de prothese, volume de prothese, technique de mastectomie, âge de la patiente, n'a permis d'ameliorer le resultat esthetique a long terme. Le facteur le plus souvent retrouve en cas de mauvais resultat esthetique etait l'existence d'une asymetrie tardive, liee a l'evolution differente des deux seins dans le temps. Conclusion. – En cas de RMP, la majorite des coques survient dans les deux premieres annees, alors que le taux de degonflage est stable dans le temps. Les resultats esthetiques suivent une courbe decroissante quasi lineaire. A cinq ans, seules 52 % des patientes gardent un resultat satisfaisant. Ces donnees ne doivent pas faire rejeter les RMP, en raison de leurs nombreux benefices et de leurs avantages, mais permettent de completer l'information fournie aux patientes, au moment du choix de la technique la plus adaptee a chaque cas.

We defined the indications for and evaluated the results of a new technique for radioguided surgery, the SiteSelect system. The procedure allows en-bloc resection of the breast parenchyma under local anesthesia.This prospective study was based on 167 patients operated on between December 2000 and October 2003 with 2 phases. The first step was an evaluation of the feasibility of the procedure with the 15-mm cannula, and the second was therapeutic with the 22-mm cannula.The mean duration of the procedure was 42 minutes. In 96.9% of procedures, the lesion was excised successfully. Only one complication (hematoma) and two failures and were observed. Histological examination revealed benign disease in 65.8% of cases and cancer in 34.2% of cases. In the latter cases, the specimen margins were histologically involved in 86.2% of cases with the 15-mm procedure and in 41% with the 22-mm procedure. During the first evaluation, all patients with a cancer underwent systematic surgical re-excision: residual tumor was present in 18 cases (64.2%). The biopsy was painless for 88 patients, and the cosmetic result was good in all cases.This study shows that the SiteSelect procedure allows resection of the lesion in 96.9% of cases. Combined with complementary surgical lumpectomy during the same operation, this procedure achieved a success rate of 98.7%. In the case of cancer, the 15-mm cannula is not wide enough to allow free margins. The use of a new 22-mm cannula, currently under evaluation, might solve this problem.

Accurate presurgical evaluation of residual disease appears essential for successful clinical outcome in patients with breast cancer who are undergoing chemotherapy. Our objective was to study the impact on surgical planning of adding serial MRI evaluations of the tumor to standard non-MRI assessments.MR images of breast tumors obtained before, during, and after preoperative chemotherapy were reviewed in 30 patients. Tumor response was assessed using both size and morphologic MRI criteria. We compared the actual surgical decisions made prospectively on the basis of standard (clinical, mammographic, and sonographic) assessments of response with decisions that would have been made had MRI findings also been considered. MRI investigators were blinded to the ultimate surgical results. Successful breast-conserving surgery was judged on pathologic confirmation of excision margins that were negative for cancer.The standard evaluation led to 16 successful breast-conserving and 14 mastectomy procedures. Using MRI results would have led to major beneficial therapeutic changes in six (20%) of the 30 patients: five patients undergoing primary mastectomy (chemotherapy avoided) and one patient undergoing postchemotherapy mastectomy (unsuccessful breast-conserving surgery avoided). MRI would have added valuable information in 14 (46.7%) of the 30 patients. In seven (23.3%) of the 30 patients, the decision to perform postchemotherapy mastectomy would have been unchanged. In one patient (3.3%), MRI results would not have prevented unsuccessful breast-conserving surgery. In two patients (6.6%), MRI results would have prevented successful breast-conserving surgery from being performed.Although the ultimate incidence of breast conservation was potentially similar for the patients (16/30, 53%) in whom the standard evaluation was used and for the patients (14/30, 47%) in whom the MRI-added evaluation was used, MRI was useful in establishing the final treatment earlier in the process, avoiding unnecessary preoperative chemotherapy, or selecting high-risk breast-conserving procedures.

Resume La technique du ganglion sentinelle permet de proposer un traitement conservateur des ganglions de l'aisselle chez des patientes presentant un cancer du sein de petite taille. Le principe de la technique est de ne prelever qu'un ganglion, dit « sentinelle », qui reflete de maniere fiable le statut ganglionnaire de l'aisselle. Le reperage de ce ganglion necessite son marquage prealable par un produit lymphophile (colorant et/ou isotope). L'objectif essentiel est de diminuer la morbidite du membre superieur liee au curage axillaire. Cette technique multidisciplinaire, associant la chirurgie, la medecine nucleaire et l'anatomopathologie, n'est pas encore validee dans ses effets a long terme, mais constitue une voie d'avenir dans la prise en charge des patientes qui pourront ainsi beneficier d'un traitement mieux adapte a chaque cas.

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

Local recurrence after lumpectomy for ductal carcinoma in situ (DCIS) is a major concern and is related to residual disease in the breast. We studied the predictive value of lumpectomy margins for residual DCIS and compared our results and pathological processing techniques with those published in the literature. Margin status was determined for 89 patients with screen-detected DCIS who had lumpectomy and re-excision, for the presence and extent of residual disease. Margin width was defined as the narrowest distance between tumor and any inked margin or, where margins were positive, classified into focal involvement (1 mm of the inked surface involved), minimal (or=115 mm) and extensive (or=15 mm). The amount of residual tumor was quantified according to the number of ducts involved with tumor: small (fewer than 10 ducts) or large (10 or more ducts) residuum. The initial margin status was a significant predictor for the presence of residual tumor in re-excision specimens (P=0.006). There was residual tumor in 44 and 45% of close non-involved (1 andor=1 mm width) margins, 67% of focally, 71% of moderately and 94% of extensively positive margins. The pathologic tumor size was also a predictor for the presence of residual tumor with 27, 68 and 74% of lesions measuringor=10, 11-25,25 mm,respectively, showing residual disease. The presence of residual tumor was not significantly related to age, mammographic appearance, nuclear grade or intraductal necrosis. The initial margin status was found to predict for the amount of residual tumor. With careful margin assessment, margin status after lumpectomy for DCIS can be used to predict for the presence and amount of residual tumor in the breast and is a guide to further management decisions. A standard for margin status reporting and pathological processing of screen-detected DCIS in situ lesions will help in the interpretation of data from different institutions.

Resumen La cirugia es un aspecto esencial del tratamiento del cancer de mama. Permite el control local de la enfermedad y establecer su pronostico. Requiere un conocimiento anatomico preciso de la vascularizacion y del drenaje linfatico de la mama. Gracias al tratamiento multidisciplinario del cancer de mama, a su deteccion precoz y al desarrollo de nuevas tecnicas quirurgicas, el tratamiento conservador es cada vez mas frecuente, con un doble objetivo permanente: mejorar las tasas de curacion y dejar una mama sin deformidades ni secuelas. La cirugia ganglionar sigue basandose en la linfadenectomia axilar, pero la busqueda del ganglio centinela con metodos colorimetricos o isotopicos es cada vez mas popular, especialmente en los tumores pequenos, en los que las metastasis axilares son cada vez mas raras. En este articulo se tratan las tecnicas de referencia, tales como la tumorrectomia, la mastectomia y la limpieza axilar, y se comentan los fundamentos basicos de la cirugia oncoplastica y de la tecnica del ganglio centinela.

Purpose Axillary dissection is the standard management of the axilla in invasive breast carcinoma. This surgery is responsible for functional sequelae and some options are considered, including axillary radiotherapy. In 1992, we published the initial results of a prospective randomized trial comparing lumpectomy plus axillary radiotherapy versus lumpectomy plus axillary dissection. We present an update of this study with a median follow-up of 180 months (range, 12 to 221 months). Patients and Methods Between 1982 and 1987, 658 patients with a breast carcinoma less than 3 cm in diameter and clinically uninvolved lymph nodes were randomly assigned to axillary dissection or axillary radiotherapy. All patients underwent wide excision of the tumor and breast irradiation. Results The two groups were similar for age, tumor-node-metastasis system stage, and presence of hormonal receptors; 21% of the patients in the axillary dissection group were node-positive. Our initial results showed an increased survival rate in the axillary dissection group at 5 years (P = .009). At 10 and 15 years, however, survival rates were identical in both groups (73.8% v 75.5% at 15 years). Recurrences in the axillary node were less frequent in the axillary dissection group at 15 years (1% v 3%; P = .04). There was no difference in recurrence rates in the breast or supraclavicular and distant metastases between the two groups. Conclusion In early breast cancers with clinically uninvolved lymph nodes, our findings show that long-term survival does not differ after axillary radiotherapy and axillary dissection. The only difference is a better axillary control in the group with axillary dissection.

Aims: Tamoxifen is widely used as adjuvant therapy in receptor positive post menopausal breast cancer. Little is known about its efficacy as neo adjuvant therapy in terms of breast conservation and improved survival. Methods: We analyzed the tumour response to 20–30 mg Tamoxifen for 6 months in post menopausal patients with oestrogen receptor positive tumours. Treatment included Tamoxifen for 6 months, surgical resection, and irradiation for post menopausal patients refusing initial mastectomy; aged≥70 years; or with other factors delaying surgery. Results: Between April 1994 and June 1998, 102 patients, age 73±87 (54–90) were studied. There were 24 T1, 56 T2, 14 T3, and 8 T4 tumours. Clinical response to Tamoxifen was observed in all patients, with a median size reduction from 31±15 (9–70) to 16±9 mm (0–50), 15 clinical and 6 complete responses. 88/102 patients were treated conservatively. Radiotherapy was given to 80 and a flash technique to 8 patients. All patients but one are still alive. Conclusion: Neo adjuvant Tamoxifen in operable post menopausal ER positive breast cancer is associated with a good clinical response rate and facilitates conservative surgery. Tamoxifen has a valuable role as neo-adjuvant treatment in terms of breast conservation and survival.

Background In a significant proportion of women with breast cancer, the sentinel node is the only involved node in the axilla. The purpose of this study was to identify factors associated with histologically positive non-sentinel lymph nodes. Methods Between 1997 and 2002, 800 women with early breast cancer underwent sentinel node biopsy. In 263 patients the node contained metastases, including 83 with micrometastases detected by immunohistochemistry (IHC), 40 micrometastases detected on haematoxylin, eosin and safranine (HES) staining, and 140 macrometastases. All clinical and histological criteria were recorded and analysed with reference to histology of the non-sentinel node. Results The risk of metastasis in the non-sentinel lymph node was related to the volume of the tumour in the sentinel node. Non-sentinel nodes were involved in five (6·0 per cent) of 83 women when the sentinel node contained only micrometastatic cells detected on IHC, and in three (7·5 per cent) of 40 women when micrometastases were detected by HES, compared with 55 (39·3 per cent) of 140 when the sentinel node contained macrometastases on HES staining. Univariate analysis revealed a significant association between non-sentinel node involvement and type of metastasis within the sentinel node, clinical primary tumour size, palpable axillary lymph nodes before operation, pathological primary tumour size and the presence of peritumoral lymphovascular invasion. On multivariate analysis, the type of metastasis within the sentinel node (P < 0·001), histological tumour size greater than 20 mm (P = 0·017) and the presence of palpable axillary nodes before operation (P = 0·014) remained significant. Conclusion Clinical and pathological factors associated with sentinel node histology can reliably predict women for whom further axillary clearance is recommended, but it is not yet possible to determine a subgroup of patients in whom the sentinel node is the only involved node and for whom further axillary treatment may be unnecessary.

A 28-year-old woman underwent mammary lymphoscintigraphy for evaluation of the sentinel node status of a small infiltrating ductal carcinoma in the central, lower, and outer quadrant of the left breast confirmed by biopsy. The patient was scheduled for lumpectomy and sentinel node biopsy. Lymphoscintigraphy showed increased uptake at two sites of the peritumorally injected tracer (60 MBq; 1.6 mCi rhenium sulfur nanocolloid) in internal mammary nodes, two of which were located most proximal to the tumor and related to the tumor by two distinct lymphatic ducts. An axillary lymph node was also detected. At surgery, the gamma probe confirmed the location of all the hot spots, and four nodes were harvested: one axillary, two first internal mammary nodes in the third intercostal space, and one internal mammary node in the second intercostal space. Histologic analysis revealed that the axillary sentinel node was free of disease, but the two first intramuscular sentinel nodes were metastatic. The second-echelon internal mammary node above the sentinel nodes (second intercostal space) was free of disease. This case shows the benefit of imaging all the drainage pathways of a breast tumor and retrieving nonaxillary lymph nodes, which may be the only positive nodes. As a result of the findings, the patient's prognosis may be altered and the subsequent therapeutic approach may be modified. Although exclusive involvement of the internal mammary chain is well established and relatively rare (occurring in approximately 5% of cases), it is important to remember that the axillary status of a breast tumor is not the only major prognostic factor.