Expérience guinéenne de la chirurgie conservatrice du cancer du sein

Objective

To evaluate the first results of conservative breast cancer surgery in surgical oncology unit of Donka University Hospital, Conakry, Guinea.

Patients and methods

Between 2007 and 2012, 140 surgical interventions for breast cancer were performed. In the present study, we report the case of 12 patients who underwent conserving breast surgery for breast cancer stages I (4), IIA (2) and IIB (6). The indication was based on the stage and the initial diagnostic procedure. In case of correlation between clinical examination, mammography and pathological review, quadrantectomy axillary dissection (QAD) were performed. If the tripod was discordant, a QAD was indicated in the case of lymphadenopathy or a quadrantectomy in the absence of axillary lymphadenopathy. Depending on the result of the histological examination of the surgical specimen, adjuvant chemotherapy and radiotherapy were recommended. Neoadjuvant chemotherapy was administrated for tumours whose size was greater than 3 cm. Thus, the following treatments were performed: QAD (8 cases), quadrantectomy (4 cases), neoadjuvant chemotherapy (3 cases), adjuvant chemotherapy (7 cases) and radiotherapy (6 cases). Post-operative complications, local control and survival of patients were studied.

Results

Postoperative complications observed for 3 cases were as follows: seroma (3 cases), breast lymphedema (2 cases), dysesthesia in the inner face of arm (1 case) and cosmetic sequelae of breast surgery (1 case). The magnetic resonance imaging of the remaining breast showed a residual suspected tumour in only 1 out of 6 cases. This patient underwent a radical mastectomy secondarily. After a median follow up of 32.0 months, all patients were alive without recurrence.

Conclusion

The newly introduced conserving breast surgery in Guinea is an effective alternative for the treatment for early diagnosed breast cancer. It must obey the respect resection margins and consider aesthetic imperatives.     

Impact de l’atteinte du ganglion sentinelle sur la stratégie thérapeutique des cancers du sein

The status of the axillary lymph nodes is the most important prognostic factor in breast cancer. Positive sentinel lymph node may be divided into two categories: metastatic, that is, pN1, and minimal lymph node involvement, that is, pN1mi and pN0i+. Postoperative management of pN1 patients following SNB (sentinel node biopsy) is same as pN1 patients following axillary lymph node dissection, whereas postoperative management of pN1mi and pN0i+ patients is still debated, with a trend to do a complementary axillary lymph node dissection because of the risk of positive-non-SNB. This risk is evaluated approximately 1015% (reclassifying in pN1) and can modify irradiation fields and adjuvant systemic therapy. Recent papers concerning the prognosis of these patients are published since 2008. The size of node metastasis seems to be correlated with 5-year distant free metastasis survival as well as the 10-year overall survival and has been described as a decisive factor for adjuvant systemic therapy. Analysis of lymphatic dissemination remains necessary in the management of breast cancer, and analysis of minimal lymph node involvement gives the surgeons an opportunity to play a role in optimizing the postoperative treatment and the prognosis of our patients.     

Impact de l’alimentation sur le pronostic du cancer du sein

It is generally recognised that overweight and obesity at the time of diagnosis are risk factors for breast cancer recurrence and mortality. This effect is likely to be observed whatever the age at the time of diagnosis, except that for women aged 85 and over, a low BMI might cause frailty. A large prospective study indicated that an increase in weight after diagnosis is also a risk factor for recurrence and breast cancer mortality. Such an observation awaits confirmation. Adipose tissue is a source of estrogen synthesis through the activity of aromatase on steroids. However, high levels of insulin, as found in metabolic syndrome, can stimulate tumour cell proliferation and might therefore be a target for lifestyle intervention. Currently, calorific restriction with weight loss has been shown to be the most successful nutritional intervention in overweight or obese women and can be further improved by physical activity.     

Le point de vue de gynécologues impliquées dans le suivi après cancer du sein sur le PPAC

The Cancer Survivorship Care Plans (SCP) aim to organize the post-cancer care and to give a new prominence to out-of-hospital health professionals. The structured follow-up (FU) based on a determined schedule is able to help professionals to comply with good practices and women to be regularly followed. Nowadays, the implementation of the SCP has been of limited scale and generally SCP are conceived without the inputs of non-hospital physicians. No assessment has been yet performed. Based on our more than 10 years experience of breast cancer patients FU in the network Gynecomed, we consider that the SCP improve the monitoring after cancer if a real cooperation has been set up between hospital and out-of-hospital physicians. This implies a co-construction FU process, a shared protocol, a mutual training process, a recall procedure, an information system between in and out hospital professionals allowing to discuss individual cases.     

Le ganglion sentinelle dans les carcinomes épidermoïdes de la tête et du cou

Node involvement is a major prognostic factor in head and neck cancers. Among N0 staged patients, because 15 to 30% have occult node metastasis, systematic radical modified neck dissection is frequently performed, although it is subsequently demonstrated to have been unnecessary in two thirds of the cases. With respect to minimal invasive surgery, an understanding of the head and neck lymphatic anatomy and experience of sentinel node biopsy in cutaneous melanoma and breast cancer endorse such an approach, particularly for T1–T2 N0 head and neck squamous cell carcinoma of the oral cavity and oropharynx. Progress in histological diagnosis is expected by way of targeted cervical lymphatic molecular analysis.     

Controverse sur l’irradiation de la chaîne mammaire interne dans le cancer du sein

Irradiation of lymph nodes areas after surgery of breast cancer, and specifically of the internal mammary chain, is an open question, frequently discussed. Three randomised trials (French, European-EORTC, Canadian) have been recently published or presented. The French trial did not show any benefit for internal mammary chain irradiation, but it was probably underpowered. The EORTC and Canadian trials demonstrated an improvement in overall survival after lymph nodes irradiation, including the internal mammary chain. The absolute benefit is 1.6% (hazard ratio–0.88 in a recent meta-analysis). Because this benefit is limited, it is important to define the characteristics of the patients who may benefit from this irradiation. Analyses of the randomized trials are not complete, and it is difficult at this moment to accurately define this population. However, cardiac and pulmonary toxicity of lymph nodes irradiation is well known. For each patient, evaluation of the potential late toxicity must be evaluated and so an accurate dosimetry for critical organs must be performed: the indication of internal mammary chain irradiation depends of the benefit/risk ratio.     

L’association hormonothérapie-thérapie ciblée dans le cancer du sein

Approximately 70–80% of breast cancers expressed estrogen receptors (ER). Endocrine therapy is the main pillar of the medical management of women with ER+ breast cancer. Since its use, endocrine treatment has radically changed the fate of breast cancer ER + with marked improvement of progression-free survival and overall survival. However, the benefits of the endocrine therapy are limited by the development of resistance. Experimental studies concluded that resistance to the endocrine therapy occurs at least in part via activation of several intracellular signal transduction pathways of cell proliferation. These observations have encouraged a number of phase II/III clinical trials evaluating different approaches of using the signal transduction inhibitors (STI) in combination with endocrine agents. These trials evaluated the feasibility and the capacity of these combinations to delay or to prevent endocrine resistance and are reviewed hereunder.     

Le Bulletin de l’Association française pour l’étude du cancer de 1909 à 1914 : le Bulletin du cancer dans sa première période

Three years after its founding in 1909, the Association française pour l'étude du cancer is a major scientific society developing transdisciplinary debates particularly on innovative therapeutics in cancer, such as the developing use of radium. The Association at that time assembles together all the French medical elite. Reading the Bulletin offers a clear view of the brilliant monthly debates. First World War stopped the life of the Association for four years. After this break, the set up of dedicated centers for cancer treatment was responsible for a major turn in the Association's life.     

Honte et image spéculaire : l’expérience de la stomie dans le cancer colorectal

In cancer care, we propose an original approach to the impact of colostomy on the subjectivity of patients. Our insistence concerns the psychic work from the affect of shame. This affect persists when the patient has to match the stoma, leaving him or her isolated and suffering. Our methodology consists of qualitative statements of patient that draw the different psychic reorganization of patients, from the postoperative shock to the appropriation of the colostomy bag. The phenomenological approach to colostomy patients with cancer facilitates deciphering some affects of shame with the specular image and body schema. At the clinical level, the authors describe the psychotherapeutic support of these patients in relation to their surgical equipment.     

Les signatures moléculaires sur paraffine dans le cancer du sein : le point de vue du pathologiste

Oncology research, and particularly breast pathology, is undergoing a revolution with the advent of molecular signatures. These tools are complementary to the classical clinicopathological parameters commonly used in routine. The intrinsic signature brings, via a new taxonomy of breast cancer, a fresh look at the tumor beyond the histopathological type, grade and classic parameters of the tumor burden. Other prognostic signatures are Mammaprint?, Oncotype Dx?, and MapQant Dx?. Some of these signatures are available for formalin-fixed paraffin-embedded tissues opening the door for an use in routine setting. However, pathological evaluation is still cornerstone for the optimal management of patients with breast cancer, with the back up of molecular signatures particularly for Hormone receptor positive, HER2 negative patients. Furthermore, true predictive signature are highly awaited.     

Chimiothérapie néo–adjuvante dans le cancer du sein

Sans résumé     

Bénéfices de la radiothérapie avec asservissement respiratoire dans le traitement du cancer du sein

PurposeThe purpose of this study was to compare free-breathing radiotherapy, end-expiration gating and end-inspiration gating for left breast cancer, with respect to the target volume coverage and dose to organs at risk.Patients and methodsSixteen patients underwent 3D and 4D simulation CT. For each patient, five dosimetric plans were compared: free breathing, end-inspiration gating, end-expiration gating, and two optimised plans with a 3 mm reduction of the posterior field edge to create optimised end-inspiration and end-expiration plans. Dose–volume parameters, including planning target volume coverage and dose to lung, heart and left anterior descending coronary artery were analysed.ResultsPlanning target volume coverage was adequate and similar in the five dosimetric plans (P = 0.49). Significant advantage was found for end-inspiration gating in sparing the ipsilateral lung, heart and left anterior descending coronary artery compared to free-breathing 3D radiotherapy. Optimised end-inspiration was even more favourable than end-inspiration gating (P < 0.05), with less dose delivered to the ipsilateral lung, heart and left anterior descending coronary artery. When compared to end-expiration gating, end-inspiration gating dosimetric outcomes were similar regarding lung and left anterior descending coronary artery doses, but the heart dose was inferior on the end-inspiration gating compared to end-expiration gating.ConclusionBreathing-adapted radiation therapy allowed for dose reduction to organs at risk (left lung, heart and left anterior descending coronary artery), while keeping the same planning target volume coverage. Therefore it can be considered as an interesting option for left breast cancer radiation treatment.     

Vécu psychologique de l’annonce du cancer du sein au Sénégal

To announce cancer is a difficult exercise to which are confronted professionals. Paradoxical informations are given to the patient or to his surround. The objective of this study is to improve the conditions of announcement the breast cancer diagnostic in Senegal. The authors do inventory of fixtures by describing unfolding conditions of this announcement in order to point out to the shortage in taking care patients’ feelings and for professionals to become aware of patients’ real-life experience of announcement and their expectations. The real-life experience of the announcement is sometimes “traumatic”, often reducing patients’ resilience capacities.     

Fracture de côte suite à la radiothérapie peropératoire dans le cancer du sein. Cas clinique et expérience locale

Intra-operative radiotherapy for breast cancer has been developed throughout the last two decades. It is already well-established regarding local control and toxicity for intra-operative radiotherapy using electrons as we now have the necessary background knowledge. However, very few data on later toxicity are available for intra-operative radiotherapy using low-energy photons. We report here the case of a 36-year-old woman who experienced rib fracture following intra-operative and external radiotherapy. This patient has been included in the Targit-boost trial. The intra-operative irradiation has been operated with an INTRABEAM device delivering low-energy photons of 50-kV.