Utility of Quantitative 99mTc-MAA SPECT/CT for 90yttrium-Labelled Microsphere Treatment Planning: Calculating Vascularized Hepatic Volume and Dosimetric Approach

Objectives. The aim of this study was to assess the effectiveness of SPECT/CT for volume measurements and to report a case illustrating the major impact of SPECT/CT in calculating the vascularized liver volume and dosimetry prior to injecting radiolabelled yttrium-90 microspheres (Therasphere). Materials and Methods. This was a phantom study, involving volume measurements carried out by two operators using SPECT and SPECT/CT images. The percentage of error for each method was calculated, and interobserver reproducibility was evaluated. A treatment using Therasphere was planned in a patient with three hepatic arteries, and the quantitative analysis of SPECT/CT for this patient is provided. Results. SPECT/CT volume measurements proved to be accurate (mean error <6% for volumes ≥16 cm3) and reproductive (interobserver agreement = 0.9). In the case report, 99mTc-MAA SPECT/CT identified a large liver volume, not previously identified with angiography, which was shown to be vascularized after selective MAA injection into an arterial branch, resulting in a large modification in the activity of Therasphere used. Conclusions. MAA SPECT/CT is accurate for vascularized liver volume measurements, providing a valuable contribution to the therapeutic planning of patients with complex hepatic vascularization

Prognosis for Isolated Skin Recurrence after Breast Cancer Treated by Mastectomy

Abstract. Isolated skin recurrence after mastectomy (ISRAM) for breast cancer is a rare event for which treatment is difficult and subject to debate. Patients The natural history of breast cancer treated by mastectomy is recovery or recurrence in the form of local or local and distant metastases. Local isolated skin recurrence (i.e. with no detected concomitant metastatic disease) after mastectomy (ISRAM) is still a rare event whose frequency is estimated at 5.2% to 9% (1, 2). It gives rise to two problems with no clear solution. The first problem relates to treatment in the absence of a current consensus on management and the diversity of clinical situations, and the second relates to prognosis (3). This paper reviews 75 records of patients presenting with ISRAM who were treated at the Eugène Marquis Comprehensive Cancer Center, Rennes, analyzing the prognostic factors of skin recurrence. Patients and Methods A retrospective study was conducted based on 75 records located using data software developed by the Eugène Marquis Comprehensive Cancer Center, covering patients presenting with ISRAM who were treated at the Eugène Marquis Comprehensive Cancer Center in Rennes from 1976 to 2006. The data were taken from consultation and operating room records, and histology results. ISRAM was defined by the first-time appearance of one or more nodules embedded in the skin of the hemithorax after mastectomy (region limited by the collarbone superiorly, the posterior axillary line laterally, the sternum interiorly and the submammary fold inferiorly). The parameters analyzed were the initial clinical features at the time of primary breast cancer treatment, the histological features of the primary tumor and its treatment, the clinical features of skin recurrence and its treatment, and disease development. The mean age of patients on initial diagnosis of cancer was 47.4 years (26 to 89 years, median 46 years). A family history of 1st or 2nd degree breast cancer was found in 29.33% of patients, and 12% had a previous history of fibrocystic mastopathy. The histological type of the primary tumor was (a) invasive ductal carcinoma (57% ), (b) invasive lobular carcinoma (11% ), (c) invasive carcinoma associated with an in situ component (29% ), and (d) carcinoma in situ (3% ). According to the TNM classification, there were 31% of T1, 31% of T2, 9% of T3 and 4% of T4 lesions, with 36% of N1 patients. Mastectomy was directly performed in 54.7% of patients and as second-line therapy in 45% of cases in the event of local recurrence after primary conservative treatment. Radiotherapy was administered to 73% of patients, either after systematic tumor resection or after primary mastectomy, in the case of a bulky lesion (exceeding 5 cm, pT3), or skin invasion (pT4). Adjuvant treatment following initial systemic treatment with chemotherapy or hormon

Atypical hyperplasia of the breast: the black hole of routine breast cancer screening.

International audienceAIM: Determination of the prevalence, of the radiological and clinical characteristics, and outcome of atypical hyperplasia (AH) of the breast within a population subjected to routine screening (double-view mammography with double reading, performed every two years between 50 and 75 years of age). PATIENTS AND METHODS: The clinical and radiological records and histological findings of percutaneous and surgical biopsy specimens of sixty-eight patients presenting with AH were reviewed together with patient follow-up data after percutaneous and surgical biopsy. RESULTS: AH incidence in the population was 0.19‰ with the following distribution of lesions: atypical epithelial hyperplasia (AEH, 53%), columnar cell metaplasia with atypia (CCMA, 32%), and lobular intraepithelial neoplasia (LIN, 8%). The mean patient age was 58 years and 24% of patients were receiving hormone replacement therapy. The main radiological finding was the presence of microcalcifications for AEH and CCMA lesions in particular, and the mammograms were valid (correlation between American College of Radiology score and risk of lesion, only 3% of lesions were recognized on the second reading). A total of 13.7% of AH cases were underestimated and a real risk of AH progression was observed, regardless of whether or not surgical biopsy had been performed. CONCLUSION: The clinical and radiological characteristics of AH observed in a population subjected to routine breast cancer screening are identical to those for patients with the same lesions referred to specialist centers. Surgical biopsy remains the recommended option due to the risk of underestimation of lesions by percutaneous biopsy and the risk of progression justifies the need for continued close monitoring

Quality of life and female sexual function after skinning vulvectomy with split-thickness skin graft in women with vulvar intraepithelial neoplasia or vulvar Paget disease.

International audienceOBJECTIVE: Vulvar intraepithelial neoplasia (VIN) and vulvar Paget disease are managed with either vulvectomy, destructive treatments (laser, antimitotic drugs) or immunostimulants. All these options are associated with functional complications. The purpose of this study was to evaluate the surgical technique consisting of skinning vulvectomy with split-thickness skin graft, and its effect on overall quality of life and sexual function. METHODS: A retrospective study was conducted on thirteen patients who underwent skinning vulvectomy with split-thickness skin graft between 1999 and 2009. Overall quality of life and sexual function were assessed with the Medical Outcome Study Short Form 36 (MOS SF-36) and Female Sexual Function Index (FSFI), respectively. RESULTS: The median age of patients was 54 (range: 33-77) years. Three patients had Paget disease and 10 patients had VIN lesions. The excision margins were clear in 46% of cases. The incidence of occult cancer was 31%. The mean follow-up period was 77 (±35) months. Four patients experienced a relapse of their intraepithelial disease. The mean disease-free survival was 58 (±44) months. There was no significant difference in MOS SF-36 scores between the study population and the general population. The patients assessed with the FSFI regained normal sexual function after the surgical procedure. CONCLUSION: Skinning vulvectomy with split-thickness skin graft is a feasible technique yielding good results in terms of quality of life and sexual function. It enables occult cancer to be diagnosed in patients with VIN or Paget disease

Differences in breast carcinoma in situ between menopausal and premenopausal women.

International audienceAIM: To seek differences between ductal carcinoma in situ (DCIS) according to the menopausal status of patients and to analyze their repercussions on patient care. PATIENTS AND METHODS: A multicenter retrospective study of 384 patients from 3 centers specialized in breast cancer surgery was carried out based on an analysis of the various characteristics (clinical, therapeutic, histologic, outcome) of DCIS between two groups of post- and pre-menopausal patients. RESULTS: At the time of diagnosis, 58.6% of the patients were menopausal. Compared to these patients, DCIS in premenopausal women was more frequently associated with initial clinical signs (p=0.006), a larger tumor size (p=0.02), involved margins after initial surgery (p=0.005), and surgical re-excision (p=0.03). The mammograms of the menopausal patients indicated a worse prognosis (using the American College of Radiology Classification) (p=0.025), and according to the histology report findings, more marked comedo necrosis (p=0.01). There was no difference in the other criteria (nuclear grade, multifocality, benign lesions associated with malignancy, relapse and its time of occurrence). The use of hormone replacement therapy had no effect on these data. CONCLUSION: The characteristics of DCIS are similar, whether occuring before or after the menopause, but the phenotypic expression is different. Menopausal status should not be a criterion for changing patient care

Sentinel lymph node analysis in breast cancer: contribution of one-step nucleic acid amplification (OSNA).

International audienceOne-step nucleic acid amplification (OSNA, Sysmex, Kobe, Japan) offers an excellent opportunity for accurate exhaustive sentinel lymph node (SLN) examination in breast cancer patients. Calibrated with conventional postoperative histology, this molecular technique yields comparable results intraoperatively, expressed as micrometastasis, macrometastasis or no metastasis depending on the CK19 mRNA copy number amplified in SLN lysates. We applied OSNA to detect metastasis in 810 SLNs from 367 patients with early stage breast cancer. We compared the rate of OSNA-positive SLNs in patients with invasive breast cancer (< 2 cm) versus the rate observed in a historical cohort using conventional histological examination of SLNs. No significant difference was observed, the OSNA assay was positive in 24.4% of patients, compared with positive histology in 24.8% in the historical cohort if including patients with isolated tumour cell (ITC) and in 23.4% excluding them. Opportunities for optimised patient management using OSNA are discussed: intraoperative detection of OSNA-positive SLNs enables axillary lymph node dissection (ALND) during the same procedure; standard OSNA techniques enable the establishment of homogeneous groups based on examination of whole SLNs for valid comparisons between different centres

Chemotherapy for inoperable advanced or metastatic cholangiocarcinoma: retrospective analysis of 78 cases in a single center over four years.

International audienceBACKGROUND: Systemic chemotherapy is the treatment of choice for inoperable (advanced or metastatic) cholangiocarcinoma. According to phase II and III trials, regimens combining 5-fluorouracil (5FU) or gemcitabine with a platinum salt have provided an overall response rate of 12-50% with a median overall survival of 5-16 months. METHODS: This was a retrospective analysis of 78 consecutive cases of inoperable cholangiocarcinoma treated by palliative chemotherapy from July 2005 to November 2009 in one center. We firstly aimed to evaluate the impact of palliative chemotherapy in terms of survival and secondly to analyze possible related prognostic factors. RESULTS: This cohort included 25 female and 53 male patients, with a mean age of 60.8 ± 11.4 years. Intrahepatic and extrahepatic cholangiocarcinoma were observed in 57 and 21 patients, respectively. First-line chemotherapy regimens were as follows: gemcitabine (n = 7), gemcitabine plus oxaliplatin (with or without cetuximab; n = 62) and 5FU plus cisplatin (n = 9). None of the patients achieved a complete response. The partial response rate was 35.9% (27/78), and the stable disease rate was 26.9% (21/78), giving a disease control rate of 62.8%. At the time of this analysis, with a median follow-up of 18 months, 13 patients were survivors. Median overall survival was 10 months [95% confidence interval (CI) 7-12], and median progression-free survival was 7 months (95% CI 6-8). Upon univariate analysis, only the distribution of the disease was significantly linked with prognosis, with a median overall survival of 10 months (95% CI 10-24) for solitary tumors versus 7 months (95% CI 6-11) in the case of infiltrative or multifocal tumors (p = 0.039). CONCLUSION: The disease control rate, overall survival and progression free-survival in this single-center retrospective study were in agreement with earlier reports. Specific features of this cohort were a large proportion of cholangiocarcinoma with associated cirrhosis (n = 30/78, 38.5%), mostly intrahepatic (n = 25/30, 83.5%). This confirms the increasing incidence of intrahepatic localization and the epidemiological link recently reported between intrahepatic biliary tract carcinoma and cirrhosis

Intraoperative touch imprint cytology of axillary sentinel nodes for breast cancer: a series of 355 procedures.

International audienceAIMS: Our objective was to evaluate intraoperative sentinel node touch imprint cytology (IOSNTI) for breast cancer. Three hundred and fifty-five patients with invasive breast cancer (pT1N0, lobular or ductal subtype) were included in our study. IOSNTI consists of touching glass slides to the surfaces of interest after gently pressing the spatially localized specimen, taken according to predetermined conditions, in order to perform a final histological examination consisting of H&E and immunohistochemical staining. RESULTS: The total sensitivity (Se) of IOSNTI was 36% and 15% of patients with nodal metastasis went undetected during the intraoperative examination. Sensitivity was significantly lower for the oldest patients (aged over 57 years: 25%), small tumors (smaller than 12 mm: 23.3%), lobular subtypes (8.3%), in the absence of vascular emboli (33%) and for detection of micrometastases (10%). DISCUSSION: This simple, fast and relatively inexpensive method could be combined with intraoperative molecular biology methods in populations in which cytology is less efficient and produces negative results

Isolated skin recurrence following salvage mastectomy for intramammary recurrence (after initial breast conservation therapy): is it a fatal event?

International audienceAIMS: The authors analyzed the outcome of patients with Isolated Skin Recurrence After Salvage Mastectomy (ISRASM) performed after conservative treatment for breast carcinoma, taking into account initial tumor characteristics, intramammary recurrence (first recurrence) characteristics, local skin recurrence (second recurrence) characteristics, and the type of treatment at each stage of the breast cancer continuum. METHODS: Forty-two patients who had ISRASM between 1976 and 2007 were included in this retrospective study. Twenty-six factors were studied in univariate and multivariate analyses. RESULTS: Mean Overall Survival (OS) was 70.3 (±4.1) months. The 5-year OS rate was 66.6%. 31% of patients did not present any recurrence, 52% had locoregional recurrence and 14% metastatic recurrence following ISRASM. Univariate analysis showed that 4 prognostic factors were significantly related to OS and/or Disease-Free Survival (DFS): (1) initial chemotherapy after primary breast cancer (P = 0.09 and 0.01 respectively), (2) presence of emboli at the site of intramammary recurrence (first recurrence) (P = 0.02 and 0.03), (3) interval between first and second surgery of less than 3 years (P = 0.09 and 0.0003), and (4) inflammatory skin involvement at ISRASM (P = 0.005 and 0.17). Multivariate analysis showed that presence of emboli at the site of intramammary recurrence was significantly related to OS and that an interval between first and second recurrence of less than 3 years was significantly related to DFS. CONCLUSION: Our results show that ISRASM affects a group of breast cancer patients with predominantly local rather than metastatic disease. Prognostic factors depend on characteristics at initial breast cancer, first recurrence and second recurrence. Evidence-based guidelines are still required for ISRASM management