Search

Abstract During the last two decades the number of breast implants used in aesthetic, oncologic and risk reducing surgery has increased substantially mainly due to the improvement and confirmed safety of these devices. Since identification of the first case of anaplastic large cell lymphoma associated with a breast implant (BIA-ALCL) 20 years ago, there has been an increase in the number of reports of this very rare disease, demonstrating a clear association with breast implants. Whilst the majority of cases are localised and cured by implant removal and full capsulectomy, a small percentage require chemotherapy and the mortality rate is very low. The evidence linking BIA-ALCL to implant surface texturing, as the majority of cases were diagnosed in patients with textured implants, has raised concerns about the long term safety of these devices resulting in patient and regulatory authority concerns globally. We hereby present the current published knowledge about the link between BIA-ALCL and implant surface texture and a review of current regulatory and professional body advice across Europe, which may enable a better understanding of this rare disease, how to manage and ultimately prevent it. We conclude by giving EUSOMA recommendation, towards the unnecessary change in attitudes towards implant based surgery, according to the most recent available published evidence as long as patients are properly informed about the risk of BIA-ALCL. [ABSTRACT FROM AUTHOR]

Résumé L’irradiation fait partie intégrante du traitement conservateur, optimisant le taux de contrôle local et améliorant celui de la survie. L’augmentation régulière de l’incidence du cancer du sein, les contraintes liées à l’irradiation en fractionnement classique et la saturation des services de radiothérapie ont conduit à la réalisation d’une étude pilote et trois essais randomisés qui ont testé différentes modalités d’irradiation hypofractionnée. Environ 7000 patientes ont été incluses et les suivis varient de 5 à 12 ans. Les conclusions sont similaires, avec une équivalence de taux de contrôle local et de toxicité par rapport au schéma classique. Trois modalités peuvent être donc utilisées : 42,5 Gy en 16 fractions et trois semaines, 40 Gy en 15 fractions et trois semaines ou 42 Gy en 13 fractions et cinq semaines. Toutefois, ces essais comportent des limitations, car ils ont inclus des patientes atteintes de cancer avec des facteurs histopronostiques favorables, qui ont été irradiées très majoritairement dans le sein et pour qui, quand elle était indiquée, le boost a été délivré en fractionnement classique. Par conséquent, ces schémas doivent être utilisés essentiellement pour des patientes atteintes de tumeurs de stade T1-T2 sans envahissement ganglionnaire et nécessitant une irradiation mammaire exclusive. Si un boost est délivré, celui-ci est en fractionnement classique. Il est indispensable d’éviter les hétérogénéités dosimétriques pouvant conduire à délivrer de fortes doses par fraction aux organes critiques tels que le poumon ou le cœur. Breast irradiation after breast-conserving surgery is essential for maximizing local control and overall survival. The increase of breast cancer (BC) incidence, constraints of classical five weeks (w) radiation regimens and scarcity of radiotherapy units have led to test short hypofractionated WBRT schemes. One pilot study and three prospective randomized trials have tested various hypofractionated regimens of WBRT. About 7000 patients were included and follow-up ranged from 5 to 12 years. The conclusion of these trials is similar, showing local control and toxicity equivalent to these of the standard regimens. Three schemes are now clearly validated: 42.5 Gy/16 fr/3 w, 40 Gy/15 fr/3 w, or 42 Gy/13 fr/5 w. However, the majority of included patients had favorable prognostic factors, were treated to the breast only and the boost dose, when indicated, was delivered with a standard fractionation. Therefore, we recommend the regimens preferentially in patients treated to the breast only, and without nodal involvement. These studies did not evaluate the addition of a boost dose with a hypofractionated scheme. If a boost is to be given, a standard fractionation should be used. Particular care should be taken to avoid heterogeneities leading to high fraction doses to organs at risk (lung and heart). [ABSTRACT FROM AUTHOR]

Purpose Ductal carcinoma in situ represents 15 to 20% of all breast cancers. Breast-conserving surgery and whole breast irradiation was performed in about 60% of the cases. This study reports local recurrence rates in patients with ductal carcinoma in situ treated by breast-conserving surgery and whole breast irradiation with or without boost and/or tamoxifen and compares different therapeutic options in two European countries. Patients and methods From 1998 to 2007, 819 patients with pure ductal carcinoma in situ were collected, both in France (266) and Italy (553). Median age was 56. All underwent breast-conserving surgery and whole breast irradiation; 391 (48%) received a boost (55% in France and 45% in Italy, P = 0.017) and 173 (22.5%) tamoxifen (4.5% in France and 32% in Italy, P < 0.0001). Results With a 90-month median follow-up, there were 51 local recurrences (6.2%), including 27 invasive (53%). The 5- and 10-year local recurrence rates were 4% and 8.6%. Two patients developed axillary recurrence and 12 (1.5%) metastases (seven after invasive local recurrence); 41 (5%) patients had contralateral breast cancer. In the multivariate analysis, high nuclear grade and lack of tamoxifen are the most powerful predictors of local recurrence, with 2.6 (95% confidence interval [95% CI]: 1.74–3.89, P = 0.0012) and 2.85 (95% CI: 1.42–5.72, P = 0.04) odds ratio (OR) estimates, respectively. Age, margin status and boost did not influence local recurrence rates. Conclusions This study confirms the ductal carcinoma in situ treatment heterogeneity among countries and the unfavourable prognostic role of nuclear grade. Tamoxifen reduces local recurrence rates and might be considered for some subgroups of patients, but further confirmation is required. The boost usefulness still remains unclear. [ABSTRACT FROM AUTHOR]

Purpose Several studies showed a breast cancer downstaging due to screening. A first national survey was conducted in France in 2001–2002 to evaluate in the current clinical practice the clinicopathological features and treatments of 1049 firstly operated breast cancers. In order to assess the impact of the national screening program implemented in all regions in France in 2004, a new survey was performed in 2007–2008. Material The new survey included 1433 firstly operated breast cancers prospectively collected. These new data were compared to the results of the first national survey. Results According to TN classification, we found in the second survey T 0 : 27.6%, T 1 : 48.6%, T 2 : 21.3%, T 3 T 4 : 3.8% and T x : 0.7%. Infiltrating ductal and lobular carcinomas represented 80% and 13% of tumours. Hormone receptors were positive in 85.3% and Her-2 overexpressed in 12.4% of tumours (83.9% and 20.6% in the first survey); 68.2% and 32% were pN 0 and pN 1-3 . Lumpectomy and mastectomy were performed in 77% and 23% of the cases. Axillary dissection, sentinel node biopsy or both were performed in 42.6%, 41% and 16.4% of the cases, respectively. Radiotherapy, chemotherapy, hormonotherapy and trastuzumab were given to 93%, 51%, 83% and 9.3% of the patients. Compared with the results from the first survey, we found an increase of infraclinical lesions (T 0 from 8.4 to 27.6%) and a wide decrease of pN+ rate (from 44% to 32%). The mastectomy rate was constant (23%), as well as radiotherapy use, whereas chemotherapy use decreased from 62.8 to 55.6%. Conclusion A complete national screening coverage clearly provides a favourable modification of breast cancer clinicopathological features. Both locoregional and adjuvant treatments were greatly downscaled. [ABSTRACT FROM AUTHOR]

Abstract: Background: Infiltrating MBC represents less than 1% of all male cancers. Our study details clinico-pathological features, treatments and prognostic factors in a large French cohort. Material and methods: Four hundred and eighty-nine patients were collected from 1990 to 2005. Median age was 66 years (34% over 70 years) and median follow-up 58 months. Results: According to TN classification, we found T1: 39%, T2: 41%, T3T4: 9%, T x : 11% and N1N2: 27%. Lumpectomy (L) and mastectomy (M) were performed in 8.6% and 91.4% of the cases. Axillary dissection (AD), sentinel node biopsy or both were performed in 90%, 2% and 5% of the cases, respectively. Ninety-five percent of tumours were ductal carcinomas; 47% were pT1, 20% pT2 and 33% pT3–T4. Axillary nodal involvement was present in 52.8% cases. ER and PgR were positive in 92% and 89% cases. Radiotherapy (RT) was performed in 85% of the patients. Hormonal treatment (HT) was delivered in 72% of the cases. Tamoxifen and aromatase inhibitors were used in 85% and 12% of the cases; 34% of the patients received chemotherapy (CT). Local recurrence (LR), nodal recurrences (NR) and metastases occurred in 2%, 5% and 22% of the cases; 2% and 10% developed contralateral BC and second cancer. The 5- and 10-year overall survival (OS) rates were 81% and 59%; disease-specific survivals (DSS) were 89% and 72%. Death causes were BC 56%, second cancer 8%, complications 3%, intercurrent disease 15% and unknown 18%. In a univariate analysis, metastatic risk factors were T stage (T1: 19%, T2: 26%, T3T4: 40%; p =0.013), pN status (pN0: 12% pN1–3: 26% pN>3: 44%; p <0.0001) and presence of locoregional recurrence (62% versus 18% p <0.0001). In a multivariate analysis, axillary nodal involvement and high SBR remain prognostic factors. Conclusion: Earlier diagnosis and wide use of adjuvant treatments (RT/HT/CT) widely decreased LR and increased survival rates in MBC, reaching female ones. Prognostic factors were also very similar to female ones. [Copyright &y& Elsevier]

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<0.0001). Nuclear grade was high in 21% of patients, intermediate in 38.5% and low in 40.5%. Excision was considered complete in 92% (CS) and 88.3% (CS+RT) of patients. Oestrogen receptors were positive in 69.8% of assessed cases (31%). Treatment modalities varied widely according to region: mastectomy rate, 20-37%; adjuvant RT, 84-96%; hormone treatment, 6-34%. Our survey on current DCIS management in France has highlighted correlations between pathological features (tumour size, margin and grade) and treatment options, with several similar variations to those observed in recent UK and US studies. [ABSTRACT FROM AUTHOR]

Data derived from histopathological analysis, natural history, radiological characteristics, molecular markers, and clinical outcome indicate that ductal carcinoma in situ (DCIS) is a heterogeneous disease, meaning that no one treatment strategy is best, but rather that treatment should be personalised and entail a systematic and rigorous multidisciplinary approach. Many women with DCIS will develop actual invasive carcinoma over time, whereas others-especially those with low-grade cancers-will not. At the moment, identification of patients at low risk of recurrence risk is very difficult (that is, such people for whom further treatment beyond lumpectomy is not needed). In this context, molecular profiling analysis is a promising method to guide management decisions. In this Review, various treatment strategies for DCIS will be reviewed, highlighting the limitations of randomised trials. Furthermore, discussions about the role of sentinel-node biopsy and tamoxifen in disease management; locoregional recurrence; and special clinical scenarios such as recurrent disease, DCIS after thoracic radiotherapy, ductal carcinoma with concurrent lobular carcinoma in situ, and DCIS in elderly people and in men will be presented. [ABSTRACT FROM AUTHOR]

The increasing incidence of DCIS during the past 20 years needs a continuous evaluation of the treatment strategies and a multidisciplinary decision process. The management of the DCIS remains a challenging issue in 2003. Mastectomy should still be considered as the reference treatment which is able to guarantee cure in almost all cases, whereas breast conserving surgery followed by radiation therapy is associated with 7–10% of local recurrence. However, the increasing knowledge of the predictive factors of the local recurrence allows to propose a conservative treatment strategy to a large amount of patients, without negative impact on their prognosis. This review presents the arguments that permit to justify the reasoned choice of the different therapeutic options according to the clinico-pathological situations. [Copyright &y& Elsevier]

Focuses on the treatment strategies of Hodgkin's disease (HD). Description of standards, options and recommendations for the management of HD in 2001; Use of surgery, radiotherapy and chemotherapy for the treatment of HD.

Presents guidelines of Standards, Options and Recommendations for nonmetastatic breast cancer. Pathological examination and classification of frozen sections of tumors; Investigation for the detection of metastatic disease; Histological classification of breast cancer.

Résumé Objectifs Le cancer du sein chez l’homme est une affection rare, de ce fait mal connue. Il ne représente que 0,6 % de tous les cancers mammaires, et moins de 1 % de la pathologie cancéreuse chez l’homme. Les objectifs de l’étude étaient d’analyser les caractéristiques cliniques, histologiques et thérapeutiques de 95 hommes pris en charge pour un cancer du sein entre 2000 et 2010 dans 4 centres hospitaliers, et déterminer des facteurs prédictifs de mauvais pronostic, afin d’améliorer la prise en charge. Méthodes Il s’agit d’une étude multicentrique et rétrospective. L’analyse des dossiers cliniques de cette série s’est effectuée sur différentes structures hospitalières, regroupant le groupe hospitalier Sud Réunion (GHSR), le centre hospitalier de Dax, l’institut Bergonié (centre de lutte contre le cancer de Bordeaux et du Sud-Ouest) et le centre René-Gauducheau (institut de cancérologie de l’Ouest). Tous les carcinomes in situ ou infiltrants du sein, survenus chez des patients de sexe masculin, ont été inclus. Une analyse des caractéristiques cliniques, histologiques et thérapeutiques a été réalisée. Les analyses statistiques de notre étude ont porté sur les survies globale et spécifique des patients selon la méthode de Kaplan-Meier, permettant ainsi de rechercher des facteurs prédictifs de mauvais pronostic. Résultats L’âge moyen était de 65 ans. Trente-sept pourcent des patients présentaient un surpoids ou une obésité. La maladie s’est révélée, dans 88 % des cas, sous forme d’une tumeur palpable, avec une taille clinique moyenne de 26,29 mm. Sur 90 patients, aucun ne présentait une lésion non palpable T0, 44 % une tumeur T1, 38 % une tumeur T2, 3 % une tumeur T3, et enfin 10 % une tumeur T4. Le type histologique le plus fréquent était le carcinome canalaire infiltrant 87 %. Une proportion identique de patients avec ou sans envahissement ganglionnaire était retrouvée. Chez les patients N+, une rupture capsulaire était observée dans 29 % des cas. Une positivité des récepteurs avait été constatée, aux œstrogènes dans 95 % des cas et à la progestérone dans 83 % des cas. Sur l’ensemble des patients, 93 soit 98 % avaient bénéficié d’une mastectomie. Sur l’ensemble des mastectomies, 83 étaient associées à un curage axillaire. L’irradiation complémentaire était pratiquée chez 75 % des patients et la chimiothérapie chez 37 % des patients. La survie globale était de 79,2 % à cinq ans et 70,8 % à dix ans. L’âge, la taille histologique tumorale et la rupture capsulaire sont des facteurs qui influencent de manière significative les survies globales et spécifiques. Conclusion Le cancer du sein chez l’homme est une pathologie différente du cancer du sein chez la femme. La majorité des recommandations suggère de traiter les hommes qui sont diagnostiqués avec le cancer du sein en utilisant les lignes directrices appliquées aux femmes ménopausées. Il n’y a aucune étude basée sur la population masculine qui a évalué ces modalités de traitement en termes d’impact sur la survie. Le diagnostic est en général fait à des stades plus avancés, et la taille tumorale est souvent supérieure. Les caractéristiques histologiques diffèrent également. Pourtant le traitement reste quasiment identique. Objectives The optimal treatment for male breast cancer is not known because male breast cancer is a rare disease. It represents as little as 0.6% of all breast cancers and less than 1% of human cancers. The aim was to analyze the clinical, histological and therapeutic characteristics of 95 men cared for breast cancer between 2000 and 2010 in four hospitals, and determine predictors of poor prognosis to improve care of male breast cancer. Methods This study is a multi-institutional survey, retrospective, involving four French institutions: Cancer Institute of the West (ICO), Reunion Island South hospital group, the hospital group of Dax, and the Bergonié Institute. All carcinomas in situ or invasive breast occurred in male patients were included. An analysis of clinical, histological and therapeutic features was performed. Statistical analysis of our study focused on the overall survival of patients and specific method of Kaplan-Meier, enabling search for predictors of poor prognosis. Results The mean age was 65 years. Thirty-seven percent of patients were overweight or obese. It was in 88% of cases of palpable tumor whose average size was 26.29 mm. Ninety patients, none had a lesion palpable T0, 44% T1 tumors, 38% T2 tumors, 3% had a T3 tumors, and finally 10% T4 tumors. The histological type was the most common invasive ductal carcinoma (87%). He found a similar proportion of patients with or without lymph node involvement. N+ patients, capsular rupture was observed in 29% of cases. Receptor positivity was found, estrogen in 95% of cases and progesterone in 83% of cases. Additional irradiation was performed in 75% of patients and chemotherapy in 37% of patients. Overall survival was 79.2% at five years and 70.8% at ten years. Age, tumor size and histological capsular rupture are factors that significantly influence the overall survival and specific. Conclusion Male breast cancer is a different pathology of breast cancer in women. The majority of recommendations suggest treating men who are diagnosed with breast cancer, using the guidelines applied to postmenopausal women treatments. There is no study based on male population that has evaluated these treatment modalities in terms of impact on survival. The diagnosis is usually made at later stages, and tumor size is often greater. Histological characteristics also differ. However, the treatment is almost identical. [ABSTRACT FROM AUTHOR]

To define a set of quality indicators that should be routinely measured and evaluated to confirm that the clinical outcome reaches the requested standards, Eusoma has organised a workshop during which twenty four experts from different disciplines have reviewed the international literature and selected the main process and outcome indicators available for quality assurance of breast cancer care. A review of the literature for evidence-based recommendations have been performed by the steering committee. The experts have identified the quality indicators also taking into account the usability and feasibility. For each of them it has been reported: definition, minimum and target standard, motivation for selection and level of evidence (graded according to AHRO). In overall 17 main quality indicators have been identified, respectively, 7 on diagnosis, 4 on surgery and loco-regional treatment, 2 on systemic treatment and 4 on staging, counselling, follow-up and rehabilitation. Breast Units in Europe are invited to comply with these indicators and monitor them during their periodic audit meetings. [Copyright &y& Elsevier]

Résumé Dans le cancer du sein, la radiothérapie est un élément essentiel de la prise en charge. Après traitement conservateur pour un carcinome infiltrant, l’irradiation complémentaire doit être systématique, quelles que soient les caractéristiques de la patiente, car elle diminue le taux de rechute locale et améliore par-là la survie. L’irradiation partielle n’est pas une technique de routine mais peut être proposée à des patientes sélectionnées et dûment informées. Pour les carcinomes canalaires in situ, l’irradiation doit également être systématique après tumorectomie. Après mastectomie, une irradiation pariétale complémentaire s’impose pour les patientes atteintes d’une tumeur classée pT3–T4, envahissant ou non les ganglions, quel que soit le nombre de ganglions atteints. Après chimiothérapie néo-adjuvante et mastectomie, et en l’absence d’atteinte ganglionnaire durant l’intervention, l’irradiation est préconisée s’il existait une lésion classée T3–T4 ou une atteinte ganglionnaire clinique ou radiologique avant la chimiothérapie. L’irradiation axillaire n’est, la plupart du temps, pas indiquée après curage chirurgical ; elle se discute en cas de ganglion sentinelle atteint et en l’absence de curage. L’irradiation des aires sus- et sous-claviculaires est préconisée en cas d’atteinte histologique axillaire. L’irradiation mammaire interne se discute au cas par cas, en évaluant le rapport bénéfice-risque (toxicité cardiaque). Une dose de 45–50 Gy est délivrée dans la totalité du sein en fractionnement classique. Un complément de dose ( boost ) dans le lit tumoral doit être délivré chez les patientes de moins de 60 ans après traitement conservateur. Des modalités d’hypofractionnement sont possibles après tumorectomie, si les aires ganglionnaires ne nécessitent pas d’irradiation (42,5 Gy en 16 fractions, ou 41,6 Gy en 13 ou 40 Gy en 15). La délinéation du sein, de la paroi et des aires ganglionnaires repose à la fois sur des données cliniques et radiologiques. La technique usuelle reste l’irradiation conformationnelle tridimensionnelle, la radiothérapie en modulation d’intensité n’ayant que des indications limitées. L’asservissement respiratoire pourrait être utile en cas de dose reçue par le cœur excessive. L’administration concomitante de la chimiothérapie adjuvante est déconseillée. En revanche, l’hormonothérapie peut être débutée en même temps que l’irradiation. In breast cancer, radiotherapy is an essential component of the treatment. After conservative surgery for an infiltrating carcinoma, radiotherapy must be systematically performed, regardless of the characteristics of the disease, because it decreases the rate of local recurrence and by this way, specific mortality. Partial breast irradiation could not be proposed routinely but only in very selected and informed patients. For ductal carcinoma in situ, adjuvant radiotherapy must be also systematically performed after lumpectomy. After mastectomy, chest wall irradiation is required for pT3–T4 tumours and if there is an axillary nodal involvement, whatever the number of involved lymph nodes. After neo-adjuvant chemotherapy and mastectomy, in case of pN0 disease, chest wall irradiation is recommended if there is a clinically or radiologically T3–T4 or node positive disease before chemotherapy. Axillary irradiation is recommended only if there is no axillary surgical dissection and a positive sentinel lymph node. Supra and infra-clavicular irradiation is advised in case of positive axillary nodes. Internal mammary irradiation must be discussed case by case, according to the benefit/risk ratio (cardiac toxicity). Dose to the chest wall or the breast must be between 45–50 Gy with a conventional fractionation. A boost dose over the tumour bed is required if the patient is younger than 60 years old. Hypofractionation (42.5 Gy in 16 fractions, or 41.6 Gy en 13 or 40 Gy en 15) is possible after tumorectomy and if a nodal irradiation is not mandatory. Delineation of the breast, the chest wall and the nodal areas are based on clinical and radiological evaluations. 3D-conformal irradiation is the recommended technique, intensity-modulated radiotherapy must be proposed only in case of specific clinical situations. Respiratory gating could be useful to decrease the cardiac dose. Concomitant administration of chemotherapy in unadvised, but hormonal treatment could be start with radiotherapy. [ABSTRACT FROM AUTHOR]

Objectif Dans les recommandations actuelles, l’utilisation d’un schéma hypofractionné pour l’irradiation adjuvante des cancers du sein infiltrants constitue une alternative à l’utilisation du schéma classique de 50 Gy en 25 séances. Il est réservé aux femmes de plus de 50 ans, atteintes d’un cancer de pronostic favorable. Dans cette étude, nous avons recueilli les informations concernant les patientes de plus de 70 ans, ayant reçu une irradiation adjuvante hypofractionnée, entre 2004 et 2012, au sein des départements de radiothérapie de Nantes et Angers, quels qu’étaient leurs facteurs histopronostiques et quel qu’était le type de chirurgie première. Patientes et méthodes Les dossiers de 205 patientes d’âge moyen 80 ans ont été analysés. Toutes ont reçu une irradiation de 45 Gy en 15 fractions de 3 Gy, à raison de trois séances par semaine. Quarante-trois pour cent ont eu une mastectomie et huit ont reçu une chimiothérapie, 32 % des patientes ont également reçu une irradiation ganglionnaire, selon le même, schéma et 49 % un complément de 9 Gy, dans le lit de tumorectomie. Résultats Avec un suivi médian de 4 ans, il a été seulement noté sept rechutes locales et cinq récidives ganglionnaires. La probabilité de rechute locale était inférieure à 5 % à 5 ans. Quatre-vingt-six pour cent des patientes ont été atteintes d’une radio-épithéliite aiguë, dont respectivement dans 75 %, 20 % et 5 % des cas de grades 1, 2 et 3, 56 % des irradiations concernaient le côté gauche. Il a été noté 15 % de fibroses postradiques et aucune toxicité pulmonaire ni cardiaque à long terme n’a été identifiée. Conclusion Pour les patientes âgées, l’irradiation hypofractionnée adjuvante semble une bonne alternative, avec un bon taux de contrôle local, et sans majoration de toxicité, y compris après mastectomie ou en cas d’irradiation ganglionnaire associée. [ABSTRACT FROM AUTHOR]