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Background Documentation burden, defined as the need to complete unnecessary documentation elements in the electronic health record (EHR), is significant for nurses and contributes to decreased time with patients as well as burnout. Burden increases when new documentation elements are added, but unnecessary elements are not systematically identified and removed. Objectives Reducing the burden of nursing documentation during the inpatient admission process was a key objective for a group of nurse experts who collaboratively identified essential clinical data elements to be documented by nurses in the EHR. Methods Twelve health care organizations used a data-driven process to evaluate inpatient admission assessment data elements to identify which elements were consistently deemed essential to patient care. Processes used for the twelve organizations to reach consensus included identifying: (1) data elements that were truly essential, (2) which data elements were explicitly required during the admission process, and (3) data elements that must be documented by a registered nurse (RN). Result The result was an Admission Patient History Essential Clinical Dataset (APH ECD) that reduced the amount of admission documentation content by an average of 48.5%. Early adopters experienced an average reduction of more than two minutes per admission history documentation session and an average reduction in clicks of more than 30%. Conclusion The creation of the essential clinical dataset is an example of combining evidence from nursing practice within the EHR with a set of predefined guiding principles to decrease documentation burden for nurses. Establishing essential documentation components for the adult admission history and intake process ensures the efficient use of bedside nurses' time by collecting the right (necessary) information collected by the right person at the right time during the patient's hospital stay. Determining essential elements also provides a framework for mapping components to national standards to facilitate shareable and comparable nursing data.

Background.Autologous fat grafting (AFG) is a widely used procedure in breast reconstruction after breast cancer. Indications are in constant increase but there is a lack of dataabout global morbidity, especially fat necrosis and management of local complications. The purpose of this study was to evaluate the complications rate in term of abnormal clinical examination or imaging and the proportion of additional explorations. Methods. We retrospectively reviewed the computerized files of consecutive patients who underwent AFG for breast reconstruction after breast cancer or for preventive surgery and aesthetic sequelae after lumpectomy in the Oscar Lambret center between January 2013 and December 2016. Fat grafts were harvested with a fat trap then processed and injected according the Coleman technique. We collected demographics, operative details, local complications, incidence of palpable masses and/or suspicious breast imaging findings leading to additional explorations (breast imaging or biopsy), and locoregional cancer recurrence. Descriptive statistics were generated. Results. Over a 4-year period, 257 women underwent autologous fat grafting for breast reconstruction and aesthetic sequelae after lumpectomy. Their mean age was 50 years [range 28-75], the mean BMI was 25 [range 18-44], 26% (n=66) were smoking and 74% (n=190) underwent radiotherapy. A total of 303 breasts were operated by 270 mastectomies (89%) or33 lumpectomies (11%). The reconstruction was delayed in 63% (n=171) and the main techniques used were breast implant (44%, n=119) and autologous latissimus dorsi (31%, n=84). The mean number of fat grafting procedures was 1,9 per patient [range 1-7] with a mean volume of 181 mL [range 30-535]. The mean time interval between cancer diagnosis and first fat graft session was 56 months [range 3-285], and the follow-up ranged from 0 to 51 months (mean=16). The prevalence of donor site complications was 6% (n=16) and infections was 2% (n=5). Sixty six (25,6%) patients had a clinically palpable lesion and 54 (21%) underwent additional imagings, mostly by ultrasounds (53 patients, 98%) except the usual follow-up. Twenty one biopsies (8%) were performed and showed 16 benign results (76,2%) and 5 malignant results (23,8%) leading to 6,2% of fat necrosis and 1,9% of locoregional recurrence after AFG in our study.Tobacco (p=0.45), BMI (p=0.95), radiotherapy (p=0.56) and amount of fat grafted ( p=0.09) didn't appear to be risk factors for fat necrosis. Conclusions. A good knowledge of local complications by surgeons and radiologists enables to avoid systematic and repeated further imaging explorations. Multicentric, prospective studies with long term follow up and evaluation of patients reported outcomes are needed to evaluate anxiety generated by biopsies and costs generated by repeated imagings. Key words: autologous fat grafting, breast cancer, local morbidity, fat necrosis. Citation Format: Hannebicque K, Renaudeau C, Giard S, Regis C, Boulanger L, Bogart E, Le Deley M-C, Ceugnart L, Chauvet M-P. Evaluation of autologous fat grafting local morbidity (fat necrosis and biopsy rates) in breast reconstruction after breast cancer: A retrospective study on 257 patients in Oscar Lambret Center [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-16-04.

Background: Breast reconstruction (BR) for women who undergo mastectomy for cancer offers psychological benefits and improves quality of life. However its use remains limited, especially for women over 65 years, with a large degree of international variation. The aim of this study was to find out factors influencing the surgical decision of BR in France where cancer related healthcare costs are fully reimbursed. Methods: We used the French medico-administrative database to identify all primary mastectomies for breast carcinoma in 2012 and studied the rate of immediate (IR) or delayed breast reconstruction (DR) up to December 2015. Variations of BR rates were evaluated according to - patient age, social deprivation index, - profile of the hospital where the mastectomy was performed: type of hospital (cancer center, CC; university hospitals, UH; private, PrivH; or public, PubH), and hospital activity (surgical acts for breast cancer in 2012); - disparities across administrative regions in terms of number of CC or UH, number of plastic surgeons, gynecologist-obstetrician surgeons and general surgeons in the region. A hierarchical three-level logistic regression was used with SAS GLIMMIX to model the probability of BR taking into account clustering of observations (patients in hospitals, hospitals in regions). Splines were used to explore the functional form of the relationship between continuous variables and BR rate. Akaike information criterion was used for model selection. Results: Among the 19,466 women who had a mastectomy in 2012, 5,328 (27.4%) subsequently had a BR: IR for 13.7% and DR for 13.7%. The BR rate significantly varied with age (p500), especially in older patients (varying from 3.1% to 10.3%). We also observed important heterogeneity of BR rates across administrative regions, but these variations were not explained by the number of CC or UH, the number of plastic surgeons, the number of gynecologist-obstetrician surgeons or the number of general surgeons in the region. In multivariate analysis, BR rate was significantly associated with age (p Conclusions: We identified substantial variations in BR rates across the French hospitals. Controlling for possible confounders, older patients have less breast reconstruction. This apparent heterogeneity can be part of women choice, however it suggests unequal access to high quality procedures for older women with breast cancer. Citation Format: Regis C, Le J, Le Teuff G, Cucchi M, Boulanger L, Hannebicque K, Giard S, Chauvet M-P, Quemenr J, Ledeley M-C. Variations in breast reconstruction rate in France according to patient and site characteristics: A nationwide retrospective study of nearly 20,000 patients [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 P4-13-03.

Background: Breast cancer is the most common cancer among European women with 54,000 new cases in France in 2015. Nearly 47% of these cancers are diagnosed in women aged 65 and over. Mastectomy is still needed in 30% of cases, resulting in significant physical and psychological consequences. Breast reconstruction (BR) can reduce the effects of surgical treatment and improve quality of life. However, less than 20% of women choose BR in France. This number drops to 6% for patients over 65 years old. The objective of the study was to find the factors influencing the decision-making process for attempting breast reconstruction in women who are over 65. Methods: We included retrospectively all patients over 65 years old who had an immediate or delayed breast reconstruction in our Cancer Center from January 2006 to July 2016. We set up a control group matching them with patients treated by mastectomy during the same period who did not choose BR. The matched-pair criteria were age, TNM stage and performans status, obtained from multidisciplinary consultation meeting database. We mailed to all patients a specially-designed questionnaire inspired by the BREAST-Q aimed at assessing the medical information that was delivered to them about BR and the reasons to choose or not choose reconstruction. The qualitative and quantitative results were analyzed. The two groups were compared using Chi-square, Fisher's exact, Mann-Whitney, and Student t test. Results: Among 134 patients, 103 (77%) completed the questionnaire. Dedicated information on BR before the mastectomy was provided more frequently to patients who had BR (91.7% vs 66.7% p=0.008). Forty-one percent of patients sought out sources of information other than their surgeon (other physicians, friends, other patients, the internet – no significant differences between the two groups, p=0.1). The three most important persons influencing the decision-making process were first the patient's surgeon, second the patient's husband, and third her general practitioner (GP). These people were more often in favor of reconstruction in the BR group than in the mastectomy group (respectively, 94.5% vs 22.9% p Conclusions: Providing dedicated information at the time of initial support is crucial in the choice of BR for women over 65. Patients' surgeons played a central role in the decision, but their GPs and husbands also provided important input. This dedicated information should help women over 65 to conclude that their age should not be a limiting factor for the decision to attempt breast reconstruction. Citation Format: Quemener J, Wallet J, Boulanger L, Hannebicque K, Giard S, Chauvet MP, Regis C. Determinants in decision-making process of breast reconstruction in women over 65 years old [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 P4-13-07.

Background: Recent updated analysis of the HERA (HERceptin Adjuvant) trial indicate that tumor hormone receptor status (HR)remains a major determinant of outcome in HER2-positive (HER2+) early breast cancer (BC) patients, with higher rates of recurrence and death in women with HR-negative (HR-) disease, even after 11 years' median follow-up. Furthermore, data reported from the HERA trial suggest that the timing of recurrences is different, with an initial higher frequency of disease-free survival (DFS) events in patients with HR- disease than those with HR-positive disease (HR+). No evidence of a different trastuzumab efficacy according to the HR of the primary tumor was found. In this study, we examined the impact of HR on outcome in a large, multicenter, “real-world”, retrospective cohort of HER2+ early breast cancer patients Methods: HER2+ BC were retrospectively identified from a large cohort of 23,375 consecutive patients who underwent primary surgery at 17 French centers between Dec 1987 and Jan 2014. A multivariate Cox model was built including age, tumor size, SBR grade, lymphovascular invasion, lymph node involvement, hormonal receptors status, adjuvant chemotherapy, adjuvant hormone therapy, trastuzumab, radiotherapy and type of surgery. Results: A total of 1308 cases were identified, including 829 (63%) HR+ and 479 (47%) HR- patients. Median follow-up was 52 months (range 0 to 201). Compared with HR+, HR- patients had significantly smaller tumors (37 vs. 31% ≤ 10mm, p=0.027; information for multifocal tumors was not available), with higher SBR grade (58 vs. 40% grade 3, p Conclusions: Our results suggest that HR status remains a major determinant of outcome in HER2+ BC, including the timing of recurrence. Yet, this prognostic impact appears to be mitigated by trastuzumab-based adjuvant treatment. Citation Format: de Nonneville A, Gonçalves A, Cohen M, Reyal F, Classe JM, Giard S, Colombo PE, Muracciole X, Chopin N, Lambaudie E, Houvenaeghel G. Impact of hormone receptor status in HER2-Positive early breast cancer in the trastuzumab era: Results of a National multi-institutional study [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 P1-13-04.

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.

Background Omission of completion axillary lymph node dissection (ALND) is a standard practice in patients with breast cancer (BC) and negative sentinel nodes (SNs) but has shown insufficient evidence to be recommended in those with SN invasion. Methods A retrospective analysis of a cohort of patients with BC and micrometastases (Mic) or isolated tumour cells (ITCs) in SN. Factors associated with ALND were identified, and patients with ALND were matched to patients without ALND. Overall survival (OS) and recurrence-free survival (RFS) were estimated in the overall population, in Mic and in ITC cohorts. Findings Among 2009 patients analysed, 1390 and 619 had Mic and ITC in SN, respectively. Factors significantly associated with ALND were SN status, histological type, age, number of SN harvested and absence of adjuvant chemotherapy. After a median follow-up of 60.4 months, ALND omission was independently associated with reduced OS (hazard ratio [HR] 2.41, 90 confidence interval [CI] 1.36–4.27, p = 0.0102), but not with increased RFS (HR 1.21, 90 CI 0.74–2.0, p = 0.52) in the overall population. In matched patients, the increased risk of death in case of ALND omission was found only in the Mic cohort (HR 2.88, 90 CI 1.46–5.69), not in the ITC cohort. The risk of recurrence was also significantly increased in the subgroup of matched Mic patients (HR 1.56, 90 CI 0.90–2.73). Interpretation A separate analysis of Mic and ITC groups, matched for the determinants of ALND, suggested that patients with Mic had increased recurrence rates and shorter OS when ALND was not performed. Our results are consistent with those of previous studies for patients with ITC but not for those with Mic. Randomised controlled clinical trials are still warranted to show with a high level of evidence if ALND can be safely omitted in patients with micrometastatic disease in SN.

Background: Triple-negative breast cancers (TNBCs) are the most deadly form of breast cancer (BC) subtypes. Axillary lymph node involvement (ALNI) has been described to be prognostic in BC taken as a whole, but its prognostic value in each subtype is unclear. We explored the prognostic impact of ALNI and especially of small size axillary metastases in early TNBCs. Methods: We analysed in this multicentre study all patients treated for early TNBC in 12 French cancer centres. We explored the correlation between clinicopathological data and ALNI, with a specific focus on the dichotomisation between macrometastases and occult metastases, which is defined as the presence of isolated tumour cells or micrometastases. The prognostic value of ALNI both in terms of disease-free survival (DFS) and overall survival (OS) was also explored. Results: We included 1237 TNBC patients. Five-year DFS and OS were 83.7% and 88.5%, respectively. The identified independent prognostic features for DFS were tumour size >20 mm (hazard ratio (HR)=1.86; 95% CI: 1.11–3.10, P=0.018), lymphovascular invasion (HR=1.69; 95% CI: 1.21–2.34, P=0.002) and ALNI both in case of macrometastases (HR=1.97; 95% CI: 1.38–2.81, P

Background: Nipple-sparing mastectomy (NSM) is a standard for bilateral prophylactic surgeries. However for cancer treatment, the preservation of the nipple areolar complex (NAC) is still discussed because of suspected increase of local recurrence and surgical specific complications as nipple or mastectomy flap necrosis. The aim of the study was to investigate both the relapse risk associated with NSM for breast cancer and women's satisfaction with preservation of the NAC. Methods: We included retrospectively all patients who had skin-sparing mastectomy (SSM) or NSM from 2007 to 2012 for breast cancer or ductal carcinoma in situ (DCIS). We compared NSM and SSM group for oncological (overall survival (OS) and disease-free survival (DFS)) and surgical outcomes. Patients' satisfaction and quality of life has been evaluated by a specifically designed questionnaire, addressed by mail and inspired by the Breast-Q questionnaire with specific assessment of global esthetic result, harmony with the native breast and need for psychological support. Results: During the study, we operated 5600 patients for a breast cancer, among them, 152 had NSM (n=63 / 41.5%) or SSM (n=89 / 58.5%) with immediate implant breast reconstruction. Eighty-nine (58.6%) patients had DCIS, and the other had invasive disease (86.9% of T1). The mastectomy has been indicated for primary cancer (81%) or recurrence (19%). The two groups did not differ significantly according to histological type (p=0.10), grade (p=0.84), hormonal receptor (p=0.7), HER2 (p=1.00), Ki67 (p=0.75) or node metastases (p=0.64). Median follow-up was 42 (IQR: 18-58 ) months. No cancer-related death occurred during the study. Local recurrence rate was 1.7% (n=1) in NSM group and 0% in SSM group (p=0.35). The recurrence did not appear on the preserved nipple. Severe complication requiring surgery (Grade 3 of Clavien-Dindo classification) occurred in 9.9% of the cases. In the NSM group, one patient had complete NAC necrosis and three patients suffered partial necrosis. Severe skin-flap necrosis leading to implant removal was more frequent in the SSM group (SSM: 6.7% (n=6) ; NSM: 0% (n=0); p=0.042). One hundred and four (80%) patients answered the questionnaire. Satisfaction about the aspect of the NAC was higher in the NSM group compared to SSM with delayed reconstruction of the nipple (75% vs 59%, p=0.14). Patients with NSM needed less psychological support before (p=0.028) and immediately after surgery (p=0.14) than patients in the SSM group, which may suggest a better acceptation of the surgery in this group. Conclusion: NSM for breast cancer surgery was not associated with significant increase of local recurrence rate or surgical complications. Patient's satisfaction was high. Therefore, nipple-sparing mastectomy with immediate implant reconstruction can successfully and safely be performed for pre-invasive and small invasive breast cancer. Besides esthetic aspects, preserving the nipple may ease the acceptation of these radical surgeries. Citation Format: Regis C, Mesdag V, Tresch E, Chauvet MP, Boulanger L, Collinet P, Giard S. Is nipple-sparing mastectomy with implant reconstruction for breast cancer safe and worthwhile?. [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 P2-13-09.

Resume Objectifs L’objectif etait d’evaluer les facteurs pronostiques des carcinomes lobulaires infiltrants (CLI) T1 et T2 du sein et les facteurs predictifs de l’atteinte ganglionnaire axillaire. Methodes Etude retrospective multicentrique, menee de 1999 a 2008, parmi 13 centres francais. Les donnees concernant les patientes traitees d’un cancer du sein T1 ou T2 par une chirurgie premiere ont ete recueillies. Une mastectomie partielle ou totale etait realisee avec un curage axillaire systematique durant la periode de validation ou en cas d’envahissement des ganglions sentinelles. Parmi ces 8100 patients, 940 cas de CLI ont ete extraits. Apres analyse univariee identifiant les facteurs pronostiques significatifs, une regression logistique de Cox a ete appliquee. L’analyse a permis de determiner les facteurs pronostiques de survie sans recidive (SSR) et de survie globale (SG). Les differents facteurs correles a une atteinte des ganglions lymphatiques ont ete recherches en analyse univarie, puis multivarie, afin de determiner les facteurs predictifs d’envahissement ganglionnaire axillaire. Resultats L’âge median etait de 60 ans (27–89). La majorite des patientes presentaient une tumeur d’une taille superieure a 10 mm (n = 676 : 72 %), avec une minorite de lesions de haut grade SBR (n = 38 : 4 %) et une majorite de statut hormonal positif (n = 880 : 93,6 %). La duree mediane de suivi etait de 59 mois (1–131). Les facteurs significativement associes a une diminution de la SSR etaient le grade SBR 3 (hazard ratio [HR] : 3,85, IC 1,21–12,21), la taille tumorale superieure a 2 cm (HR : 2,85, IC : 1,43–5,68) et le statut ganglionnaire macrometastatique (HR : 3,11, IC : 1,47–6,58). L’analyse multivariee mettait en evidence un impact significatif sur la SG de l’âge de moins de 50 ans (HR : 5,2, IC : 1,39–19,49), du grade SBR 3 (HR : 5,03, IC : 1,19–21,25), de la taille tumorale superieure a 2 cm (HR : 2,53, IC : 1,13–5,69). Il n’a pas ete mis en evidence de correlation significative entre la prescription de chimiotherapie et la SSR (odds ratio [OR] 0,8, IC : 0,35–1,80) ou la SG (OR : 0,72, IC : 0,28–1,82). La SSR n’etait pas differente entre les pN0 (aucune invasion axillaire), les pNi+ (cellules tumorales isolees) ou les pNmic (micrometastase). Il n’y avait pas de difference entre un ou plus d’un ganglion lymphatique macromatastatique (pN1). Les SSR etaient statistiquement differentes entre les pN1 et les autres statuts ganglionnaires (pN0, pNi+ ou pNmic). Les facteurs associes a l’atteinte ganglionnaire en analyse multivariee etaient : l’âge entre 51 et 65 ans (OR : 2,1, IC 1,45–3,04), l’âge inferieur a 50 ans (OR 3,2, IC : 2,05–5,03), la taille tumorale superieure a 2 cm (OR 4,4, IC : 3,2–6,14), le grade SBR 2 (OR 1,9, IC : 1,30–2,90) et le grade SBR 3 (OR 3,5, IC : 1,61–7,75). Conclusion L’analyse de cette serie de 940 CLI de stade T1 et T2 apporte plusieurs informations : les facteurs associes a l’atteinte des ganglions lymphatiques axillaires sont l’âge de moins de 65 ans, la taille de la tumeur de plus de 20 mm et un grade SBR 2 ou 3. Les memes facteurs sont significativement correles aux taux de SSR et de SG. L’envahissement macrometastatique des ganglions axillaires a un impact significatif sur la SSR et la SG, contrairement aux pNi+ et aux pNmic, qui semblent avoir le meme pronostic que les pN0.

Resume Objectif Malgre la standardisation de la prise en charge des cancers du sein infra-cliniques (biopsie diagnostique, reperage preoperatoire…), il existe des situations delicates avec une discordance entre un diagnostic de malignite sur la biopsie initiale et l’absence de lesion maligne sur la piece operatoire. L’objectif de cette etude etait de rechercher la frequence de telles situations dans notre pratique et la demarche effectuee pour les reclasser en 3 causes possibles : echec d’exerese sous reperage ; exerese complete lors de la biopsie ; vrais faux-positifs de la biopsie. Patientes et methodes Etude a partir d’une base de donnees d’enregistrement prospectif, incluant les patientes ayant eu une mastectomie partielle apres diagnostic sur biopsie d’un cancer invasif, ou d’un cancer canalaire in situ et chez lesquelles l’histologie de la piece operatoire ne montrait que du sein normal ou des lesions benignes. Resultats Trente-sept patientes correspondaient aux criteres de l’etude, 2 % des 1863 mastectomies partielles realisees d’emblee pour lesions malignes durant les 3 ans. Apres discussion en reunion de concertation pluridisciplinaire, 6 (16 %) ont ete considerees comme etant des echecs d’exerese, 26 (70 %) ont ete considerees comme des lesions enlevees en totalite lors de la biopsie, 5 (13,5 %) comme des vrais faux-positifs de la biopsie. Discussion et conclusion C’est la premiere serie qui s’interesse a tous les facteurs influencant la survenue de piece blanche apres biopsie positive. Situation rare, necessitant une concertation multidisciplinaire afin d’analyser toutes les etapes de la prise en charge pour determiner la cause et proposer une conduite adequate.

Sentinel lymph node biopsy (SLNB) remains under discussion for large size tumors. The aim of this work has been to study the false negative rate (FNR) of SLNB for large tumors and predictive factors of false negative (FN).A study of a multicentric cohort, involved patients presenting N0 breast cancer with a SLNB eventually completed by complementary axillary lymph node dissection (cALND). The main criteria were the FNR and the predictive factors of FN.12.415 patients were included: 748 with tumors ≥30 mm, 1101 with tumors20 and 30 mm and 10.566 with tumors ≤20 mm, with a cALND respectively for 501 patients (67%), 523 (62.1%) and 2775 (26.3%). The FNR were respectively: 3.05% (IC95%: 1.3-4.8) for tumors ≥30 mm*, 3.5% (1.8-5.2) for tumors20 and 30 mm*, 1.8% (1-2.4) for tumors ≤20 mm (p 0.05) (*Not significant). At multivariate analysis, SN number harvested ≤2 (OR:2.0, p = 0.023) and tumor size20 and 30 mm (OR:2.07, p = 0.017) were significant predictive factors of FN, without significant value for tumor size ≥30 mm (OR:1.83, p = 0.073).The FNR of SLNB was not higher amongst large size tumors compared to tumors of a smaller size. These results support the validation of SNLB for tumors up to 50 mm.

Background The preservation of the nipple areolar complex (NAC) for cancer treatment is still a matter of debate because of suspected increase of local recurrence and surgery-specific complications. The aim of the study was to investigate both the relapse risk associated with nipple sparing mastectomy (NSM) for breast cancer and women's satisfaction with preservation of the NAC. Methods We included retrospectively all patients who had skin-sparing mastectomy (SSM) or NSM from 2007 to 2012 for breast cancer or ductal carcinoma in situ (DCIS). We compared NSM and SSM group for oncological and surgical outcomes. Patients’ satisfaction and quality of life has been evaluated by a specifically designed questionnaire. Results We included 63 NSM (41.5%) and 89 SM (58.5%). Eighty-nine (58.6%) patients had DCIS, and the other had small invasive disease. Median follow-up was 42 (IQR: 18–58) months. Local recurrence rate was 1.7% ( n = 1) in the NSM group and 0% in the SSM group without recurrence in the preserved nipple. After NSM, one patient had complete NAC necrosis, and three patients suffered partial necrosis. Satisfaction with the NAC was higher in the NSM group compared to the SSM group with delayed reconstruction of the nipple (75% vs. 59%, P = 0.14). Patients with NSM required less psychological support before ( P = 0.028) and immediately after surgery ( P = 0.14) than patients in the SSM group. Conclusion NSM can successfully and safely be performed for pre-invasive and small invasive breast cancer. Besides esthetic aspects, preserving the nipple may ease the acceptance of these radical form of surgery.

At the Centre Oscar Lambret, the anticancer centre of the North of France, sentinel lymph node (SLN) procedures are routinely performed for localized (T0–T1, N0, M0) breast carcinoma without any previous treatment, in order to prevent the deleterious effects of axillary lymph node dissection. The present study was undertaken to assess if the expression in the tumor of a panel of 19 genes would allow to predict histological SLN involvement. We looked at cytokeratin 19 (CK19), mucin-1 (MUC1), mammaglobin (MGB1), cyclin D1 (CCND1), the four members of the HER/ErbB growth factor receptor family (EGFR, HER2–4), insulin-like growth factor-1 receptor (IGF-1R), estradiol receptors (ERcx, ERβ), progesterone receptor (PR), vascular endothelial growth factors (VEGF, VEGF-C), urokinase-like plasminogen activator (uPA), matrix metalloproteinases 2 and 9 (MMP2, MMP9), ets-related transcription factor ERM, and E-cadherin (CDH1). Their expression was quantified by real-time RT-PCR in 134 breast cancer samples and the relationships with SLN metastases were analyzed. A slight increase (35–40%) in CK19 and HER3 expression was observed in the tumors of patients with SLN metastases compared to those of patients without metastases, even if neither CK19 expression nor HER3 expression allowed to distinguish patients with micrometastases from patients with macrometastases. We conclude that the tumoral expression of biological parameters involved in cell proliferation or playing a critical role in the metastatic process, including tumor invasion and angiogenesis, is not strongly associated with SLN metastases.

International audience; BACKGROUND: Pure Tubular Carcinoma (PTC) of the breast is a rare histological subtype of invasive breast cancer characterized by a low rate of lymph node involvement. Currently there is no consensus on less surgical axillary node staging according to this histological subtype. METHODS: We performed a retrospective multi-institutional study. Inclusion criteria were PTC, sentinel lymph node detection (SLND) and conservative breast surgery. RESULTS: From January 1999 to December 2006, 234 patients were included in the study from 9 institutions. The median pathological tumor size was 9.59 (1-22) mm. SLN were successfully detected in 98% (229/234) of patients. Among the 234 patients, a macrometastasis was found in 6 cases (2.5%), micrometastasis in 15 cases (6.4%), and isolated cells in 2 cases (0.8%). In the case of patients with SLND macrometastasis, half of them had macrometastasis in the complementary axillary lymphadenectomy, and none in the case of SLN only micrometastasis or isolated cells. Of the 122 patients with a pathological tumor size 10 mm) was the only parameter significatively linked to the risk of lymph node involvement (p = 0.007). CONCLUSION: In a large multi-institutional series with SLND, we have shown that the risk of axillary lymph node involvement in PTC is very low. In the case of PTC

Background To estimate the proportion of elderly patients (>70 years) with breast cancer eligible for an Exclusive IntraOperative RadioTherapy (E-IORT) and to evaluate their local recurrence-free survival rate. Methods This retrospective study examining two cohorts focuses on patients over 70 years old: a multi-centric cohort of 1411 elderly patients and a mono-centric cohort of 592 elderly patients. All patients underwent conservative surgery followed by external radiotherapy for T0-T3 N0-N1 invasive breast cancer, between 1980 and 2008. Results Within each cohort two groups were identified according to the inclusion criteria of the RIOP trial (R group) and TARGIT E study (T group). Each group was divided into two sub-groups, patients eligible (E) or non-eligible (nE) for IORT. The population of patients that were eligible in the TARGIT E study but not in the RIOP trial were also studied in both cohorts. The proportion of patients eligible for IORT was calculated, according to the eligibility criteria of each study. A comparison of the 5-year local or locoregional recurrence-free survival rate between eligible vs non-eligible patients was made. In both cohorts, the proportion of patients eligible according to the RIOP trial’s eligibility criteria was 35.4 and 19.3%, and according to the TARGIT E study criteria was 60.9 and 45.3%. The 5-year locoregional recurrence-free survival rate was not significantly different between RE and RnE groups, TE and TnE groups. In both cohorts RE and (TE-RE) groups were not significantly different. Conclusions Our results encourage further necessary studies to define and to extend the eligibility criteria for per operative exclusive radiotherapy.

Background: The incidence of atypical ductal hyperplasia (ADH) is increasing due to mass screening. Because of the underestimation risk of malignancy, the management remains controversial. Our goal was to analyze clinicopathologic features of patients with ADH diagnosed on directional vacuum-assisted biopsy (DVAB). The objectives of this continuous retrospective study were to evaluate the underestimation rate of malignancy and to identify predictors of upgrade to carcinoma. Methods: Between 2003 and 2010, 3159 patients underwent stereotactic DVAB in our institute. We retrospectively evaluate clinical, mammographic and pathological features of 298 cases of ADH who underwent surgical excision in our center (93.1%). Patients with concurrent history of breast cancer, intraductal carcinoma (DCIS) associated, or with no follow-up or surgical excision on place were excluded. Histological scar of macrobiopsy was systematically searched in surgical specimens. A pathologic upgrade was defined by presence of invasive cancer or DCIS on surgical specimen. Statistical tests used were the chi-square or Fisher's exact test. Results: Among the 298 studied DVAB, 224 ADH were isolated (75.2%), 46 associated to flat epithelial atypia (15.4%) and 28 to lobular neoplasia (9.4%). 98.4% patients presented microcalcifications at diagnosis. In 52 cases, lesions were upgraded to DCIS (n = 38) or invasive cancer (n = 14). The underestimated rate was 17.5%. In 67.3% cases, upgrade lesions were low or intermediate grade DCIS. Only the history of contralateral breast cancer was significantly correlated with the underestimated rate (p = 0.04). There was no statistical difference between these 52 cases and the 246 others for: family history, size of calcification, sampling number, histological lesion, and quality of calcifications removal. Conclusions: In this study, DVAB may not be considered a therapeutic procedure in case of ADH, even in the case of complete removal of microcalcifications. It is still challenging to identify a subgroup of ADH cases with a low upgrade rate. Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P4-14-10.

The French National Cancer Institute (INCa) and Societe francaise de senologie et pathologie mammaire (SFSPM), in collaboration with a multidisciplinary experts group, have published the French national clinical practice guidelines on a selection of 11 currently debated questions regarding the management of invasive breast cancer. Those guidelines are based on a comprehensive analysis of the current published evidence dealing with those issues, secondly reviewed by 100 reviewers. Radiotherapy was concerned by five of the 11 questions: indications for the boost after whole gland irradiation; hypofractionated radiotherapy; partial breast irradiation; indications for mammary internal nodes irradiation, and indications of radiotherapy after neo-adjuvant chemotherapy.

Background: Lymph node evaluation in the management of DCIS has been completely abandoned as a result of the documented low incidence of nodal metastases ( Trial design: Patients with extensive microcalcifications on mammography and DCIS diagnosed by VAMB treated by mastectomy were included in the study. The SLN procedure was performed and intraoperative evaluation on frozen sections was carried out. If the SLN was positive an ALND was performed during the same intervention. If the SLN procedure failed or was negative an ALND was not performed. Radiography of the mastectomy specimen was performed to assist the pathologist in confirming the DCIS diagnosis, to evaluate the size and to determine concordance rates between initial VAMB diagnosis and histological analyses. Results: Fourteen French cancer centers took part in this protocol over 2 years (May 2008-December 2010). 228 patients were enrolled, including 197 DCIS on VAMB. The SLN was identified in 193 cases (98%) but one case was not documented at histology leaving 192 valid cases for analysis. Distribution of SLN results and histological lesions found on mastectomy specimens in the series ALND was not performed for non-invasive disease and negative SLN (n=114) and invasive or micro-invasive disease and negative SLN (n=51). This meant that ALND was avoided for 67.1% of the patients with invasive disease (51/76, 95%CI[56.5−77.7]), or 26.6% of patients overall (95%CI [20.3−32.8]), whereas these patients would have previously received ALND without the use of the SLN procedure. We observed 39.6% (76/192) of discordance between VAMB results and definitive results from histology analysis after mastectomy across all patients. Conclusions: SLN is a useful procedure for patients with DCIS diagnosed by VAMB treated by mastectomy and presenting extensive microcalcifications on mammography. For patients for whom microinvasive or invasive carcinoma is later identified on the mastectomy specimen, the use of this procedure makes it possible to spare over a quarter of them from ALND and the associated morbidity. Biological analyses are currently underway to determine predictive factors of invasive disease associated with DCIS. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-18-02.

Ce chapitre porte sur la prise en charge diagnostique et therapeutique d’une recidive intramammaire homolaterale isolee d’un cancer du sein ayant eu initialement un traitement conservateur. Il exclut la surveillance apres traitement de la recidive locale. La recidive locale isolee homolaterale est definie comme une recidive intramammaire dans le sein traite (y compris avec atteinte de la peau par contiguite ou nodule isole sur la cicatrice initiale mais exclut les nodules de permeation et les recidives associees a une localisation ganglionnaire ou metastatique). La tumeur initiale et la recidive peuvent etre un cancer in situ et/ ou invasif.

From March 2003 to April 2004, 77 physicians throughout France prospectively recruited 1289 ductal carcinoma in situ (DCIS) patients and collected data on diagnosis, patient and tumour characteristics, and treatments. Median age was 56 years (range, 30–84). Ductal carcinoma in situ was diagnosed by mammography in 87.6% of patients. Mastectomy, conservative surgery alone (CS) and CS with radiotherapy (CS+RT) were performed in 30.5, 7.8 and 61.7% of patients, respectively. Thus, 89% of patients treated by CS received adjuvant RT. Sentinel node biopsy (SNB) and axillary dissection (AD) were performed in 21.3 and 10.4% of patients, respectively. Hormone therapy was administered to 13.4% of the patients (80% tamoxifen). Median tumour size was 14.5 mm (6, 11 and 35 mm for CS, CS+RT and mastectomy, respectively, P

Role of MRI in the presurgical work-up of breast cancer: Appropriate utilization of MRI as a complement to mammography and ultrasound. The role of MRI for presurgical local staging of breast cancers amenable to conservative treatment has been the subject of multiple publications and tends to become a « validated » indication in routine practice. The purpose of the paper is to review the advantages and limitations of this imaging modality that is part of a comprehensive management that must be validated by clinical data especially with regards to local recurrence and survival. Knowledge of these elements combined with more precise indications should result in improved patient management while avoiding overtreatment or unnecessary anxiety-producing examinations.

Aim Sentinel lymph node (SLN) biopsy was recently recommended after prior breast tumour surgery and lymphadenectomy is not the gold standard anymore for nodal staging after a lesion's removal. The purpose of our study was to evaluate the good practices of use of SLN biopsy in this context. Patients and methods From 2006 to 2012, 138 patients having undergone a surgical biopsy without prior diagnosis of an invasive carcinoma with a definitive histological analysis in favour of this diagnosis were included in a prospective observational multicentric study. Each patient had a nodal staging following SLN biopsy with subsequent systematic lymphadenectomy. Results The detection rate of SLN was 85.5%. The average number of SLNs found was 1.9. The relative detection failure risk rate was multiplied by 4 in the event of an interval of less than 36 days between the SLN biopsy and the previous breast surgery, and by 9 in the event of using a single-tracer detection method. The false negative rate was 6.25%. The prevalence of metastatic axillary node involvement was 11.6%. In 69% of cases only the SLN was metastatic. The post-operative seroma rate was 19.5%. Conclusion Previous conservative breast tumour surgery does not affect the accuracy of the SLN biopsy. A sufficient interval of greater than 36 days between the two operations could allow to improve the SLN detection rate, although further studies are needed to validate this statement. Clinical trial registration number NCT00293865 .

To assess the prognostic factors of T1 and T2 infiltrating lobular breast cancers, and to investigate predictive factors of axillary lymph node involvement.This is a retrospective multicentric study, conducted from 1999 to 2008, among 13 french centers. All data concerning patients with breast cancer who underwent a primary surgical treatment including a sentinel lymph node procedure have been collected (tumors was stage T1 or T2). Patients underwent partial or radical mastectomy. Axillary lymph node dissection was done systematically (at the time of sentinel procedure evaluation), or in case of sentinel lymph node involvement. Among all the 8100 patients, 940 cases of lobular infiltrating tumors were extracted. Univariate analysis was done to identify significant prognosis factors, and then a Cox regression was applied. Analysis interested factors that improved disease free survival, overall survival and factors that influenced the chemotherapy indication. Different factors that may be related with lymph node involvement have been tested with univariate than multivariate analysis, to highlight predictive factors of axillary involvement.Median age was 60 years (27-89). Most of patients had tumours with a size superior to 10mm (n=676, 72%), with a minority of high SBR grade (n=38, 4%), and a majority of positive hormonal status (n = 880, 93, 6%). The median duration of follow-up was 59 months (1-131). Factors significantly associated with decreased disease free survival was histological grade 3 (hazard ratio [HR]: 3,85, IC 1,21-12,21), tumour size superior to 2cm (HR: 2,85, IC: 1,43-5,68) and macrometastatic lymph node status (HR: 3,11, IC: 1,47-6,58). Concerning overall survival, multivariate analysis demonstrated a significant impact of age less than 50 years (HR: 5,2, IC: 1,39-19,49), histological grade 3 (HR: 5,03, IC: 1,19-21,25), tumour size superior to 2cm (HR: 2,53, IC: 1,13-5,69). Analysis concerning macrometastatic lymph node status nearly reached significance (HR: 2,43, IC: 0,99-5,93). There was no detectable effect of chemotherapy regarding disease free survival (odds ratio [OR] 0,8, IC: 0,35-1,80) and overall survival (OR: 0,72, IC: 0,28-1,82). Disease free survival was similar between no axillary invasion (pN0) and isolated tumor cells (pNi+), or micrometastatic lymph nodes (pNmic). There were no difference neither between one or more than one macromatastatic lymph node. But disease free survival was statistically worse for pN1 compared to other lymph node status (pN0, pNi+ or pNmic). Factors associated with lymph node involvement after logistic regression was: age from 51 to 65 years (OR: 2,1, IC 1,45-3,04), age inferior to 50 years (OR 3,2, IC: 2,05-5,03), Tumour size superior to 2cm (OR 4,4, IC: 3,2-6,14), SBR grading 2 (OR 1,9, IC: 1,30-2,90) and SBR grade 3 (OR 3,5, IC: 1,61-7,75).The analysis of this series of 940 T1 and T2 lobular invasive breast carcinomas offers several information: factors associated with axillary lymph node involvement are age under 65 years, tumor size greater than 20mm, and a SBR grade 2 or 3. The same factors were significantly associated with the OS and DFS. The macrometastatic lymph node involvement has a significant impact on DFS and OS, which is not true for isolated cells and micrometastases, which seem to have the same prognosis as pN0.

PurposeTo determine the rate of nonsentinel lymph node (NSN) involvement at axillary lymph node dissection (ALND) and predictive factors of this involvement following detection of micrometastasis in sentinel nodes (SN).MethodsWe analyzed 700 observations of SN micrometastases with additional ALND with the characteristics of the patients, tumors, and SN.ResultsInvolvement of SN was diagnosed 388 times by serial sections (55.4%) with standard hemoxylin and eosin staining (HES) and 312 times solely on immunohistochemical analysis (IHC; 44.6%). The accurate size of the micrometastases was indicated in 488 cases: 301 larger than 0.2 mm (61.7%) and 187 ≤ 0.2 mm (38.3%). Ninety-four patients (13.4%) presented an NSN involvement with only one NSN involved in 62 cases (66%). Predictive factors of NSN involvement were in univariate analysis (pT stage [P < .000], menopausal status [P = .048], T stage [P = .006], grade [P = .013], lymphovascular invasion [LVI; P = .013], histologic tumor type [P = .017], and method of micrometastasis detection, by HES or IHC [P = .015]) and in multivariate analysis (pT stage ≤ or > 20 mm [odds ratio, 2.54], micrometastases detected by HES or IHC [odds ratio,1.734], presence or absence of LVI [odds ratio, 1.706]). Micrometastasis size ≤ or greater than 0.2 mm was not predictive.ConclusionThis study confirms the value of serial sections and the vital role played by IHC in screening for small micrometastases. Omission of additional ALND may be envisaged with minimal risk for pT1a and pT1b tumors, and pT1a-b-c tumors corresponding to tubular, colloidal, or medullar cancers.

Resume Objectif. – Evaluer les resultats de la pratique en routine de 1000 procedures de ganglion sentinelle (GS) dans le cancer du sein. Patientes et methode. – Enregistrement prospectif de 1000 procedures de GS successives, effectuees de fevrier 2001 a juin 2004. Les donnees retenues etaient la technique de reperage, les resultats de la recherche du GS, les donnees histologiques peroperatoires et definitives, les caracteristiques tumorales, la conduite therapeutique en fonction de l'etat du GS et le suivi a distance. Resultats. – Neuf cent soixante-dix-huit GS ont ete decouverts (97,8 %). En analyse univariee, l'âge, la taille tumorale (20 mm), et la technique (colorimetrique ou isotopique versus combinee) influencent significativement le taux de detection. Cent cinquante-six curages ont ete realises d'emblee (16 %), 116 dans un deuxieme temps (12 %). Sur les 923 cancers invasifs ou micro-invasifs avec GS detectes, 282 (30,5 %) GS etaient positifs, 166 (59 %) avec macrometastase, 116 (41 %) avec micrometastase. Trente-quatre pour cent des curages apres GS+ etaient positifs. L'âge et la taille de la metastase sont predictifs de la positivite du curage. Seize pour cent des GS micrometastatiques ont eu un curage positif, aucun facteur n'etait predictif de la positivite de celui-ci. Avec un recul moyen de 20 mois, quatre recidives axillaires (0,4 %) sont trouvees : une apres GS negatif sans curage (0,1 %), une apres GS positif et curage (0,1 %), une apres GS micrometastatique sans curage (4,3 %), une apres GS macrometastatique sans curage(8,3 %). Dans le groupe des cancers intracanalaires (55) ou micro-invasifs (54), deux GS (2,3 %) sont positifs (deux curages negatifs). Mais 112 patientes avaient initialement un diagnostic de carcinome intracanalaire (dont la taille necessitait une MT) porte sur biopsies percutanees : 25 avaient en fait a l'examen definitif un cancer invasif (22 % de sous-estimations) et 12 de ces cancers avaient un GS positif avec quatre curages envahis. Discussion et conclusion. – Avec un taux de detection eleve et un taux faible de recidive axillaire, la technique du GS nous parait une technique fiable, a proposer pour les cancers de petite taille N0, permettant d'eviter ainsi un curage a 70 % de ces patientes.

Aim To assess the rate of positive axillary clearance (AC) when the sentinel node biopsy (SNB) contains micrometastatic disease in invasive breast cancer and to evaluate the factors that could predict positivity. Patients and methods This is a prospective study carried out on 542 successive women undergoing SNB for unifocal T0–T1 N0 invasive breast cancer without previous treatment. Results Five hundred and twenty-five sentinel nodes (SN) were found, 142 contained metastases. Fifty-five of the positive SN contained micrometastatic disease only. Of them, 40 patients underwent completion of AC. Six out of 40 patients who had micrometastatic SN had a positive AC, five for micrometastasis between 0.2 and 2 mm (5/34), one for isolated cells in the SN (1/6). None of the studied factors (age, histological tumour size, histological grade, estradiol receptor (ER), histological tumour type, size and method of micrometastasis detection) could significantly predict the status of the AC. Conclusion As long as the results of ongoing prospective randomised studies are unknown, it remains necessary to perform AC when the SNB contains micrometastatic disease, whatever the size or the detection mode of the metastasis.

Summary version of the standards, options and recommendations for nonmetastatic breast cancer (updated January 2001)

La chirurgie moderne du cancer est de plus en plus respectueuse de l'integrite individuelle. De plus, la « pression » mediatique d'un corps eternellement parfait nous pousse a accepter de moins en moins toute idee de mutilation. L'information croissante des femmes associee a la mise en place d'une veritable politique de depistage mammographique nous amene a decouvrir de plus en plus des lesions mammaires de petite taille voire totalement infracliniques. Mais, in fine, certaines d'entre elles se reveleront etre des pathologies a haut risque de rechute locale et l'idee d'une mastectomie totale est souvent soulevee. Elle peut toutefois, en fonction de la presentation clinique de cette lesion, etre mise en balance avec un traitement conservateur assorti d'une irradiation mais en sachant qu'une rechute est possible et conduira peut etre alors a reconsiderer la mastectomie totale. Or dans ces deux cas, meme si elle parait raisonnable, il est toujours difficile pour une femme d'admettre une amputation du sein, sauf si un espoir de reconstruction peut lui etre propose. C'est dire si la problematique de la reconstruction mammaire est indissociable de l'information sur une necessaire mutilation. La question de savoir si cette reconstruction doit etre effectuee a l'heure de l'amputation ou plutot differee est au centre de ce debat. Les deux points de vue presentes ici, loin de s'opposer, presentent la synthese des arguments de l'une ou l'autre solution. Ils doivent etre connus de tout gynecologue afin de fournir a leur patiente une information la plus complete possible sur les avantages et inconvenients de chaque option en sachant que la decision finale sera prise par la patiente elle-meme en fonction de son vecu et de la perception de son image corporelle.

Contexte. - La Federation nationale des centres de lutte contre le cancer (FNCLCC) et les Centres regionaux de lutte contre le cancer (CRLCC), en collaboration avec des partenaires des secteurs publics (CHU, CHG), prives et certaines societes savantes ont entrepris, depuis 1993, d'elaborer des recommandations pour la pratique clinique en cancerologie: les « Standards, Options et Recommandations » (SOR). L'objectif de l'operation SOR est d'ameliorer la qualite et l'efficience des soins aux patients atteints de cancer en fournissant aux praticiens une aide a la decision facilement utilisable. La methodologie d'elaboration des SOR repose sur une revue et une analyse critique des donnees de la litterature scientifique par un groupe pluridisciplinaire d'experts, permettant de definir, sur la base du niveau de preuve scientifique et du jugement argumente des experts, des Standards, des Options et des Recommandations. Avant publication, les SOR sont revus par des experts independants. Objectifs. - Definir, sur la base d'une revue de la litterature et de l'accord d'experts, des Standards, Options et Recommandations pour la radiotherapie des patientes atteintes de cancers de sein infiltrants non metastatiques. Methodes. - Un groupe pluridisciplinaire mis en place par la FNCLCC a revu les donnees scientifiques disponibles concernant les cancers du sein infiltrants non metastatiques. Apres selection des articles, synthese des resultats et redaction des SOR, le document a ete soumis pour relecture et approbation a 148 relecteurs independants. Resultats. - Ce document presente le chapitre radiotherapie de la mise a jour 2001 du SOR paru initialement en 1996. Les modifications des Standards, Options et Recommandations apportees dans cette actualisation sont liees a de nouvelles publications. Les principales recommandations sont: il l'irradiation du sein apres chirurgie conservatrice diminue significativement le risque de recidive locale (niveau de preuve A) et l'irradiation de la paroi apres mastectomie diminue d'autant plus le risque qu'il existe des facteurs de recidive locale (niveau de preuve A). (2) Lorqu'une chirurgie conservatrice du sein est effectuee, une radiotherapie mammaire doit toujours etre delivree, a la dose minimale de 50 Gy en 25 fractions (standard, niveau de preuve A). (3) Chez les femmes de moins de 50 ans, un complement d'irradiation doit toujours etre delivre dans le lit tumoral, y compris lorsque les berges sont saines (standard, niveau de preuve B). (4) L'irradiation de la chaine mammaire interne est indiquee lorque la tumeur est interne ou centrale, en l'absence d'envahissement ganglionnaire axillaire (accord d'experts) et dans tous les cas d'envahissement ganglionnaire axillaire (standard, niveau de preuve B1). (5) L'irradiation des ganglions sus- et sous-claviculaires est indiquee en presence d'envahissement ganglionnaire axillaire (standard, niveau de preuve B1).

Background The French Sentimag study evaluated a non-invasive method for the localization of breast cancer sentinel lymph nodes (SLN) using SIENNA+®, a superparamagnetic iron oxide particles (SPIO), in addition to conventional techniques (radiotracer and blue dye). SIENNA+® was injected subcutaneously into the breast and detected by the SENTIMAG® handheld magnetometer probe. The results showed a good SLN identification performance but a skin discoloration was noted during this study after the SIENNA+® injection. This aim of this study was to assess the long-term duration and appearance of this dermopigmentation. Methods: 56 patients had participated in Sentimag study in our Center, 6 patients who had undergone mastectomy were excluded. We selected 50 patients who had undergone breast conservative surgery. For these patients, SLN localization was performed by both the conventional method (radiotracer and /or blue dye) and magnetic tracer, SIENNA+®. 47 patients were reviewed retrospectively from January 2015 to April 2015, 1.5 to 2 years after surgery and were assessed for skin discoloration. Results : Of the 47 patients, a dermopigmentation, from grade 1 (light yellowing) to grade 3 (dark browning) remained visible at the site of injection of SIENNA+® after 20.2 months [14.4-25.9] in 36.1% of the patients (17/47). 6.4% of 47 patients seen had grade 3 skin discoloration and 29.7% had grade 1 or 2 skin discoloration. Interestingly, no patients reported that persistent staining was a cosmetic or psychological problem. Conclusions : The use of SIENNA+® appears as an alternative method to radioisotopes for SLN identification in early breast cancer, but it may result in a prolonged-dermopigmentation at the injection site. To avoid dermopigmentation, it would be interesting to compare different techniques of SIENNA+® injection into the breast (intra-tumoral injection or a deeper periareolar injection) through a randomized trial. Citation Format: Hannebicque K, Boulanger L, Bogart E, Giard S, Chauvet MP, Houpeau JL. Long-term follow-up of persistent breast dermopigmentation after sentinel lymph node identification using superparamagnetic iron oxide particles (SIENNA+®) [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 P2-01-23.

Despite the standard management of non-palpable breast cancer (needle core biopsy diagnostic, accurate preoperative localization), there are differences in some cases between the malignant histo-pathological finding in diagnostic biopsy results and negative histo-pathological finding after surgical excision. The aim of this study is to evaluate this incidence and classifying them under three category: failure of surgical excision after preoperative identification; removal of the tumor was already completed by percutaneous biopsy; percutaneous biopsy true false positive.We conducted a study based on prospective database, all patients included in this study had partial mastectomy for ductal carcinoma in-situ or invasive cancer which was diagnosed by needle core biopsy and normal/benign after surgery.Regarding the partial mastectomy, 1863 was performed in the last three years in our center. Thirty-seven patients (2%) correspond our study criteria. After discussion of cases in our multidisciplinary reunion, 6 patients (16%) were considered as failure of surgical excision, 26 patients (70%) as true removal of the whole lesion in the core, and 5 patients (13%) as true false-positive cores.This is the first study witch investigate all factors that influence the results of negative final histo-pathological finding of surgical excision of the tumor after malignant diagnostic needle core biopsy. This rare situation need a multidisciplinary meeting to analyse all the steps of management and to determine causes of those false results and try to find adequate management to solve this problem.

Background A subgroup of T1N0M0 breast cancer (BC) carries a high potential of relapse, and thus may require adjuvant systemic therapy (AST). Patients and methods Retrospective analysis of all patients with T1 BC, who underwent surgery from January 1999 to December 2009 at 13 French sites. AST was not standardized. Results Among 8100 women operated, 5423 had T1 tumors (708 T1a, 2208 T1b and 2508 T1c 11–15 mm). T1a differed significantly from T1b tumors with respect to several parameters (lower age, more frequent negative hormonal status and positive HER2 status, less frequent lymphovascular invasion), exhibiting a mix of favorable and poor prognosis factors. Overall survival was not different between T1a, b or c tumors but recurrence-free survival was significantly higher in T1b than in T1a tumors (P = 0.001). In multivariate analysis, tumor grade, hormone therapy and lymphovascular invasion were independent prognostic factors. Conclusion Relatively poor outcome of patients with T1a tumors might be explained by a high frequency of risk factors in this subgroup (frequent negative hormone receptors and HER2 overexpression) and by a less frequent administration of AST (endocrine treatment and chemotherapy). Tumor size might not be the main determinant of prognosis in T1 BC.

Resumen Los carcinomas mamarios in situ son proliferaciones epiteliales malignas dentro del sistema ductolobular. No superan la membrana basal y por ende carecen de poder metastasico. Sin embargo, entranan un riesgo de evolucion hacia el cancer invasor. El diagnostico de carcinoma ductal in situ se ha vuelto frecuente gracias a la deteccion mamografica. Aunque el tratamiento conservador ha demostrado ser util (en particular el radioquirurgico), aun no se han definido criterios precisos para distinguir los diferentes subgrupos terapeuticos. El cancer lobular in situ es una lesion poco frecuente, considerada un factor de riesgo de cancer. En lo referido al pronostico y al tratamiento forma parte, junto con las hiperplasias lobulares, de un grupo de mastopatias con riesgo: las neoplasias lobulares.

Since tamoxifen is widely used in breast cancer treatment and has been proposed for the prevention of breast cancer, its endometrial iatrogenic effects must be carefully examined. We have investigated the association between endometrial cancer and tamoxifen use or other treatments in women treated for breast cancer in a case-control study. Cases of endometrial cancer diagnosed after breast cancer (n = 135) and 467 controls matched for age, year of diagnosis of breast cancer and hospital and survival time with an intact uterus were included. Women who had received tamoxifen were significantly more likely to have endometrial cancer diagnosed than those who had not (crude relative risk = 4.9, p = 0.0001). Univariate and adjusted analyses showed that the risk increased with the length of treatment (p = 0.0001) or the cumulative dose of tamoxifen received (p = 0.0001), irrespective of the daily dose. Women who had undergone pelvic radiotherapy also had a higher risk (crude relative risk = 7.8, p = 0.0001). After adjusting for confounding factors, the risk was higher for tamoxifen users (p = 0.0012), treatment for more than 3 years (all p < 0.03) and pelvic radiotherapy (p = 0.012). Women who had endometrial cancer and had received tamoxifen had more advanced disease and poorer prognosis than those with endometrial cancer who had not received this treatment. Our results suggest a causal role of tamoxifen in endometrial cancer, particularly when used as currently proposed for breast cancer prevention. Pelvic radiotherapy may be an additional iatrogenic factor for women with breast cancer. Endometrial cancers diagnosed in women treated with tamoxifen have poorer prognosis. Women who receive tamoxifen for breast cancer should be offered gynaecological surveillance during and after treatment. A long-term evaluation of the risk-benefit ratio of tamoxifen as a preventive treatment for breast cancer is clearly warranted.

La recherche du ganglion sentinelle (GS) dans les carcinomes canalaires in situ (CCIS) du sein est le plus souvent negative avec 2 % d’atteinte ganglionnaire. Cependant, il n’est pas rare en cas mastectomie realisee dans le cadre d’un CCIS diagnostique par macrobiopsie, de decouvrir sur la piece operatoire un carcinome infiltrant ou micro-infiltrant.

L’exploration chirurgicale de l’aisselle repond au double objectif de recueil d’information sur le statut des ganglions et de controle local en cas de ganglions metastatiques. Environ 30 % des cancers du sein T1 ou T2 sans adenopathie cliniquement palpable presentent un envahissement ganglionnaire [1], [2]. L’impact direct de ce geste axillaire sur la survie globale reste hypothetique. Jusque dans les annees 1990, cette exploration chirurgicale etait realisee par curage axillaire limite aux etages I–II de BERG [3]. Depuis, il existe une desescalade therapeutique avec d’une part l’avenement de la technique du ganglion axillaire sentinelle (GAS), d’autre part la mise en place d’outils d’aide a la decision de curage complementaire chez les patientes dont le GAS est metastatique et enfin, plus recemment, la remise en question de l’interet du curage axillaire complementaire en cas de GAS metastatique.

Purpose Ductal carcinoma in situ overall prognosis is excellent, but after breast conserving surgery, with or without radiotherapy, local recurrences can lead to locoregional or distant evolution and death. However, there are few data on optimal local recurrences treatment and long-term impact on survival. Patients and methods This study included 195 women treated from 1985 to 1996 by conservative surgery (CS) or conservative surgery followed by radiotherapy (CS + RT), presenting local recurrences, with a 156-month median follow-up. Results Eighty-two out of 195 (42%) local recurrences were non-invasive (in situ) and 113 (58%) invasive. In situ local recurrence was discovered by mammography in 80.5% of the cases versus 47.5% for invasive local recurrence (P = 0.0001). Salvage mastectomy was used in 53% of the cases after conservative surgery and 75% after conservative surgery followed by radiotherapy. The axillary nodal involvement rates were 11.8% and 25.8% among 17 and 62 patients with in situ and invasive local recurrences. Among 113 patients with invasive local recurrences and 82 with in situ local recurrences, 19 (16.8%) and three (3.6%) developed metastases, respectively. Among invasive local recurrences, comedocarcinoma subtype was highly predictive of subsequent metastases (32% versus 4.4%, P Conclusion Invasive local recurrence after ductal carcinoma in situ treatment could be a dramatic event, fully changing long-term prognosis. Early mammographic local recurrence diagnosis (if possible still at non-invasive stage) seems essential to avoid or minimize metastatic risk. Mastectomy remains the safest option but, in some cases, a new conservative approach could be discussed.

The French National Cancer Institute (INCa) and Société française de sénologie et pathologie mammaire (SFSPM), in collaboration with a multidisciplinary experts group, have published the French national clinical practice guidelines on a selection of 11 currently debated questions regarding the management of invasive breast cancer. Those guidelines are based on a comprehensive analysis of the current published evidence dealing with those issues, secondly reviewed by 100 reviewers. Radiotherapy was concerned by five of the 11 questions: indications for the boost after whole gland irradiation; hypofractionated radiotherapy; partial breast irradiation; indications for mammary internal nodes irradiation, and indications of radiotherapy after neo-adjuvant chemotherapy.

Quels sont les inconvenients des traitements face a leurs benefices possibles dans les cancers a risque intermediaire? Mais aussi dans l’information avantages/risques que nous devons a toute patiente? Comment emplit-on ces plateaux (contenu et presentation de l’information) et qui apprecie de quel cote la balance penchera?

La valeur pronostique des micrometastases (pN1mi) et des cellules isolees (pN0i+) reste tres debattue compte tenu de resultats divergents de la litterature selon les etudes et selon les modalites d’analyse ganglionnaire. Il s’agit pourtant d’un element important pour decider des therapeutiques adjuvantes lorsque la decision repose principalement sur ce facteur. L’objectif principal de cette etude est de preciser la valeur pronostique de ces atteintes des ganglions sentinelles (GS) en reference aux atteintes par une macrometastase et a l’absence d’envahissement.

La chimiotherapie neo-adjuvante (CNA) est de plus en plus utilisee dans le traitement du cancer du sein. Elle permet en effet d’evaluer la reponse tumorale, fournit les informations necessaires a l’etablissement d’un pronostic et est susceptible de permettre le recours a un traitement conservateur (TC). Si les effets secondaires du curage axillaire (CA) [1] et les benefices de la biopsie du ganglion sentinelle (GS) sont connus [2], la pertinence de cette derniere, ainsi que le moment le plus opportun pour sa realisation, demeurent controverses dans le contexte d’une CNA

Our objective was to assess the global cost of the sentinel lymph node detection [axillary sentinel lymph node detection (ASLND)] compared with standard axillary lymphadenectomy [axillary lymph node dissection (ALND)] for early breast cancer patients.We conducted a prospective, multi-institutional, observational, cost comparative analysis. Cost calculations were realized with the micro-costing method from the diagnosis until 1 month after the last surgery.Eight hundred and thirty nine patients were included in the ASLND group and 146 in the ALND group. The cost generated for a patient with an ASLND, with one preoperative scintigraphy, a combined method for sentinel node detection, an intraoperative pathological analysis without lymphadenectomy, was lower than the cost generated for a patient with lymphadenectomy [€ 2947 (σ = 580) versus € 3331 (σ = 902); P = 0.0001].ASLND, involving expensive techniques, was finally less expensive than ALND. The length of hospital stay was the cost driver of these procedures. The current observational study points the heterogeneous practices for this validated and largely diffused technique. Several technical choices have an impact on the cost of ASLND, as intraoperative analysis allowing to reduce rehospitalization rate for secondary lymphadenectomy or preoperative scintigraphy, suggesting possible savings on hospital resources.

Background Axillary lymph node clearance (ALNC) improves locoregional control and provides prognostic information for early breast cancer treatment, but effects on survival are controversial. This multicentre, randomized pragmatic equivalence trial compares outcomes for post-menopausal early invasive breast cancer patients after locoregional treatment with ALNC and adjuvant therapies to outcomes after locoregional treatment without ALNC and adjuvant therapies. Methods From 1995–2005, women aged ≥50 years with early breast cancer (tumor ≤ 10 mm) and clinically-negative axillary nodes were randomized to receive treatment with ALNC (Ax) or without (no-Ax). Adjuvant therapies were prescribed according to hormonal receptor status and individual histological results. The primary endpoint was overall survival (OS); secondary endpoints were event-free survival (EFS) and functional outcomes. The trial was terminated due to lack of equivalence and low accrual after first interim analyses. Trial registration: NCT00210236. Results Of 625 patients, 297 no-Ax and 310 Ax patients were maintained for final per-protocol analyses. OS and EFS at five years were not equivalent (Ax vs. no-Ax: 98% vs. 94% and 96% vs. 90% respectively). Recurrence was higher for no-Ax, particularly in the first five years after surgery. Axillary nodes were positive for 14% Ax patients but only 2% no-Ax patients experienced axillary node recurrence. Functional impairments were greater after ALNC. Conclusion Our results fail to demonstrate equivalence of outcomes when ALNC is omitted from post-menopausal early breast cancer patient treatment. However the low locoregional recurrence rates warrant further examination over a longer duration, in particular to consider whether these would impact on survival.