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Study Objective: To assess the surgical outcomes and long-term results of laparoscopic treatment of endometrial cancer in obese patients, and compare these results with those of nonobese women., Design: Retrospective cohort study (Canadian Task Force classification II-2)., Setting: Two referral cancer centers., Patients: Fifty-two obese and 155 nonobese women with clinical stage I endometrial cancer managed by laparoscopy from 1990-2005 in two referral centers., Interventions: Demographic, surgical, perioperative and pathological characteristics of obese women and nonobese women with endometrial cancer treated by laparoscopy were analyzed and then compared. Recurrence-free and overall survival was calculated by use of Kaplan-Meier method., Measurements and Main Results: Median BMI of the study population was 26.2 Kg/m(2). Median BMI among obese patients was 34.2 Kg/m(2). The conversion rate was independent from the BMI of the patient (3.8% vs 4.5%, p = .80). Neither mean operative time (187.5 vs 172 min, p = .11) neither hospital stay (5.2 vs 4.9 days, p = .44) were related with BMI. Lymphadenectomy was considered not feasible in 7 obese (17%) and 8 nonobese (7%) women (p = 0.09). Fewer lymph nodes were retrieved among obese women (8 versus 11, p <.0002). No differences were found between the groups in terms of perioperative complications. Median follow-up was 69 and 71 months for the obese and nonobese, respectively (p = .59). Overall and disease-free 5-year survival rates did not differ between obese and nonobese patients (90.3% and 87.5% versus 88.5% and 89.8%, respectively)., Conclusion: Despite some limitations, the laparoscopic approach seems to be particularly useful for obese patients with endometrial cancer, with similar survival and recurrence rates and without any more complications compared to the nonobese population., (Copyright © 2011 AAGL. Published by Elsevier Inc. All rights reserved.)

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., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Aim: Ovarian epithelial dysplasia (OED) was first described after prophylactic oophorectomy for genetic risk of ovarian cancer. In light of Fathalla's incessant ovulation theory, this study was set up to describe the presence of ovarian abnormalities (dysplasia) after ovulation induction and to compare dysplasia profiles in stimulated and genetic risk ovaries., Methods: One-hundred and twenty-four patients who had undergone salpingo-oophorectomies or ovarian cystectomies between 1990 and 2005 were reviewed. They were divided into three groups: (1) previous in vitro fertilisation (n=35); (2) prophylactic oophorectomies for genetic risk (n=27) and (3) fertile non-cancerous controls (n=62). Eleven cytological and architectural epithelial features were defined and a dysplasia score was calculated to quantify ovarian epithelial abnormalities., Results: Mean dysplasia score was significantly higher in the genetic risk and stimulated ovary groups than in controls (9.55 versus 3.62, p<0.0001; 7.51 versus 3.62, p<0.0002, respectively). Cytological and architectural abnormalities were more frequent in the genetic risk group, while the profile of abnormalities was different in the genetic risk and stimulated groups., Conclusions: These findings support a possible relationship between OED and the use of ovulation-stimulating drugs. The increased dysplasia score in stimulated and genetic risk ovaries might be consistent with progression towards neoplastic transformation, and may justify the use of the term dysplasia or intraepithelial ovarian neoplasia. The observation of dysplasia in the stimulated group may differentiate women at risk. Conversely, the fact that the dysplasia profile after stimulation differs from that in genetic risk ovaries suggests that ovarian stimulation may predispose to a different evolution.

Background: Ovarian epithelial dysplasia was first described after prophylactic oophorectomies for genetic risk. Ovarian stimulation has been considered as a risk factor of ovarian cancer by Fathalla's incessant ovulation theory. In this study, we have investigated the risk of ovarian dysplasia after ovulation induction., Methods: We reviewed 99 oophorectomies or cystectomies between 1990 and 2005 divided them into two groups: previous in vitro fertilization (n = 37) and a panel of fertile controls (n = 62). Eleven epithelial cytological and architectural features were defined and an ovarian epithelial dysplasia score was calculated to quantify the degree of ovarian epithelial abnormalities., Results: All the ovaries were macroscopically non-cancerous except in two patients (one endometrioid cancer and one borderline tumour). The mean ovarian dysplasia score was significantly higher in the ovulation induction group than in the control group (7.64 versus 3.62, P = 0.0002). We also found a relationship between the number of ovulation-inducted cycles and the severity of ovarian dysplasia ('dose-effect') and a relationship between time after the end of ovulation induction (over 7 years) and the severity of ovarian dysplasia ('time-effect')., Conclusions: There is probably a relationship between ovarian epithelial dysplasia and either ovulation inducing drugs or infertility. By Fathalla's incessant ovulation theory, 'the dose effect and the time effect' of ovarian stimulation may explain ovarian dysplasia formation.

Unlabelled: To make an accurate histopathological description of ovarian dysplasia in a population at genetic risk of ovarian cancer and devise an ovarian dysplasia score., Materials and Methods: In this retrospective cohort study, 90 patients who had undergone bilateral oophorectomy or ovarian cystectomy between 1992 and 2005 and whose ovaries were reported as normal were divided into two groups: Group A comprising prophylactic oophorectomies for genetic predisposition (N = 28), and Group B or control group, fertile and non-cancerous (N = 62). Eleven epithelial cytological and architectural features were defined. Ovaries were analysed and reviewed by four pathologists blinded to clinical data. An ovarian dysplasia score was devised to quantify extent of ovarian epithelial abnormalities. The degrees of ovarian epithelial abnormalities (dysplasia scores) were compared between the two groups., Results: Mean dysplasia score was significantly higher in Group A (prophylactic oophorectomies) than in Group B (control group) (9.67 vs. 4.19, P < 0.001). In Group A, we observed a gradation in the severity of the dysplastic lesions between (i) proven BRCA mutations and prophylactic oophorectomies without mutations (11.26 vs. 8.1), and (ii) according to age (10.27 after age 50 years vs. 8.6 before age 50 years, P = 0.2962)., Conclusion: These results suggest abnormalities in ovaries from high risk women. The ovarian dysplasia may be a pre-malignant, non-invasive histological lesion that could be an important step in early neoplasia.

Ovarian epithelial dysplasia has been described in the ovarian surface epithelium by histologic, morphometric and nuclear profile studies. It could represent a potential precursor of ovarian malignancy in patients with genetic risk of ovarian cancer, although its natural history and progression to carcinoma are unpredictable. Diagnosis and identification of ovarian dysplasia would certainly be useful to understand the early steps of ovarian carcinogenesis. However, dysplasia in relation with ovulation induction seems to have a different pattern. We report dysplasia definitions and the current clinical management.

Preoperative diagnosis of malignant tumors arising from mature cystic teratoma (MCT) of the ovary is not easy; malignant tumors are mostly diagnosed only postoperatively. Tumor size, serum tumor markers, and patient age have been proposed as risk factors for malignancy. This article reports a rare case of a giant, benign MCT of the ovary in a young woman (25 years old). It had a very large size (320 x 270 x 185 mm, 10 kg), a great number of teeth (> 300), and preoperative serum level of tumor markers were elevated (CA125, 875 U/mL(-1); CA19-9, 2087 U/mL(-1); CEA, 5.1 ng/mL(-1); AFP, 23.3 ng/mL(-1); SCC, 20.7 ng/mL(-1)). Based on clinical and laboratory data, tumor markers and tumor size when used alone or in combination do not appear to be useful in making a differential diagnosis between MCT and squamous cell carcinoma arising from MCT. However, radiologically detectable, well-differentiated teeth may be indicative of benignity.

Objective: To evaluate retrospectively the morbidity of four different surgical procedures for immediate breast reconstruction (IBR) in the setting of neoadjuvant chemotherapy and radiotherapy, and to determine which procedure is best adapted to these circumstances., Patients and Methods: Immediate breast reconstruction was undertaken in 101 patients who had undergone neoadjuvant chemotherapy and radiotherapy for invasive breast carcinoma. IBR was accomplished by transverse rectus abdominis musculocutaneous flap (TRAM) in 38 patients, by latissimus dorsi musculocutaneous flap with prosthesis (LDMP) in 32, by autologous latissimus dorsi musculocutaneous flap (ALDM) in 15, and by simple prosthetic implant in 26., Results: The complication rates for TRAM. LDMP, ALDM and prosthesis were respectively 50%, 37.5%, 85%, and 62%. The need for additional surgical procedure(s) was respectively 29%, 15%, 6%, and 56%. The complication rate was significantly worse (p=0.013) for ALDM (RR=1.73, IC95%=1.12-2.69), and the need for surgical revision was worst (p=0.00087).for simple prosthetic implant (RR=1.99, IC95%=1.11-3.59)., Conclusion: IBR using musculocutaneous flap is superior to the use of prosthetic implant in patients having undergone neoadjuvant chemotherapy and radiotherapy.

Objectives: To investigate the role of sentinel lymph node biopsy for microinvasive ductal carcinoma in situ of the breast., Patients and Methods: From January 2001 to January 2006, lymphatic mapping was performed using radiocolloid and/or blue dye technique. Full axillary lymph node dissection was accomplished systematically in 10 instances at the beginning of the study, and furthermore when the sentinel node was involved (macrometastatic or micrometastatic disease)., Results: Identification rate was 98% (40/41), the unsuccessful procedure occurred after incisional biopsy for diagnosis. The number of sentinel nodes removed was 2 in average (1-5). Sentinel node involvement was found in 10% of cases (4/40): 1 sentinel node macrometastasis pN1, 2 sentinel node micrometastases determined by hematoxylin and eosin staining pN1 (mi), 1 sentinel node micrometastasis detected only by immunohistochemical staining pN0 (mi)., Discussion and Conclusion: Sentinel lymph node sampling should not be currently applied for management of every ductal carcinoma in situ of the breast but a selective utilization is proposed in documented high risk subset of patients according to clinical, mammographic, and histologic features obtained by percutaneous biopsies. Ductal carcinoma in situ (DCIS) with proved or suspected microinvasion could be scheduled for sentinel node procedure a fortiori in cases undergoing mastectomy because of extensive DCIS before the occurrence of disturbances of lymphatic drainage induced by surgical breast dissection.

Objective: Identify the axillopectoral muscle (usually called Langer's axillary arch) and know the main surgical techniques of axillary sentinel node biopsies., Patients and Methods: We present the results of our five-year clinical prospective study: the presence of this anomaly is diagnosed peroperatively during a sentinel node biopsy., Results: Langer's arch is identified in 1,7%, often with an unilateral distribution. Lymph nodes are just near or behind the muscle. Sentinel node biopsy dissection is difficult in about 40%., Discussion and Conclusion: The embryological derivation and anatomical features of this muscle are described, with emphasis on the surgical applications. Its presence or absence should be ascertained in every sentinel node biopsy because of the risks of axillary dissection complications by this ectopic muscle.

Background: Giant hydronephrosis leading to obstructive jaundice in adults is extremely rare., Case: This 83-year-old woman presented obstructive jaundice that was due to blockage of the pelviureteric junction and resolved by percutaneous nephrostomy., Discussion: We discuss the pathophysiologic hypotheses and rule out mechanical compression as a cause.

Ovarian remnant syndrome is defined as residual ovarian tissue non intentionally left in place by the surgeon during a bilateral salpingo-oophorectomy. Patients present various symptoms usually including chronic pelvic pain, pelvic mass, bowel obstruction, hydronephrosis due to ureteral compression. We report a case of adenocarcinoma arising in such an ovarian remnant revealed by vaginal bleeding 5 years after total abdominal hysterectomy and bilateral oophorectomy for uterine fibroids. It was regarded as stage IIIc according to the FIGO classification because of common iliac lymph node involvement while there was no ascitis, no peritoneal nor omental implant but a unilateral hydronephrosis induced by extrinsec ureteral obstruction. Complete cytoreductive surgery was achieved including partial bladder and lower ureteral resection with colpectomy, omentectomy, pelvic and para-aortic lymphadenectomy. Paclitaxel-Platinum combination chemotherapy was given for nine cycles.

Leiomyoma of the uterus is a frequent benign tumor of non menopausal women. Among possible complications, polycythemia is rare and often unrecognised. We report a very demonstrative case, that of a 52-year-old woman, who presented initially an episode of metrorrhagia. The difficulty of diagnosis and the treatment are detailed. The different physiopathological hypotheses are discussed in order to ameliorate our knowledge about this association between fibromyoma and polycythemia, and to optimise therapeutic management.

Objectives: To determine feasibility and accuracy of SLN biopsy in locally advanced breast cancer treated by neoadjuvant chemotherapy., Materials and Methods: From April 2001 to December 2004, a prospective series was constituted of 74 women with invasive breast carcinoma T1T2T3N0N1 receiving neoadjuvant chemotherapy. The SLN located was removed using subdermal periareolar injection of radiolabelled nanocolloid and axillary lymph node dissection was systematically performed., Results: A SLN was identified in 68/74 (92%) patients. It was metastatic in 30/68 cases (44%). The false negative (FN) rate was 14% (5/35). In the subgroup of 42 patients clinically N(0) before chemotherapy, accuracy was 100 %, and FN rate 0%, in the 32 N1, accuracy was 83%, and FN rate 25%., Conclusions: SLN biopsy using a single subdermal injection of radiolabelled nanocolloid in patients with a breast cancer treated by neoadjuvant chemotherapy is technically feasible and appears to be highly accurate in the subgroup of patients with a clinically negative axilla breast cancer before treatment.

Objective: The rise of preoperative diagnosis thanks to new methods of micro and macrobiopsy and the development of sentinel lymph node have dramatically modified the surgical management of patients with breast tumor. The purpose of this study is to know if extemporaneous exams still have a place in the management of breast cancer., Patients and Methods: Retrospective study which compares the qualitiative evolution of frozen sections in breast tumor at Jean-Perrin center before the practice of percutaneous strereotaxic biopsy and after the training of sentinel lymph node operative biopsy., Results: The results were in favour of a different distribution of anatomocytopathological activity with a decrease of frozen section in breast tumor and an increase of cytological imprints on sentinel nodes., Discussion and Conclusion: The interest of histologic preoperative diagnosis and the failure of consensus in the sentinel lymph node just leave a restrictive position to frozen section in breast cancer.

The clinical benefits of endocrine therapy for patients with hormonosensitive breast cancer are well established. For many years, five years' treatment with tamoxifen was the gold standard of adjuvant treatment. The recent development of new endocrine agents provides physicians with the opportunity to take a more effective therapeutic approach. Nevertheless, the success of neoadjuvant endocrine therapy is much more recent and less frequently reported in the literature. This article reviews the studies published on neoadjuvant endocrine treatment (tamoxifen and aromatase inhibitors). According to the literature, neoadjuvant endocrine therapy seems to be effective and well tolerated. The newer generation of aromatase inhibitors (letrozole, anastrozole, exemestane) appear to result in better overall response rates and more conservative surgery than tamoxifen. Patients with an ER Allred score of 6 and over are most likely to respond and gain clinical benefit. The optimal duration of neoadjuvant therapy has not yet been investigated in detail. These preliminary results are interesting and should be confirmed by further studies.

Objectives: To review and describe the anatomoclinical cases of the endometrial cancers arising on polyps during a hormonotherapy by tamoxifen for breast cancer., Patients and Methods: In the surgical inventory 1990-2002 of the benign or malignant uterine lesions investigated by hysteroscopy with dilatation & curettage (D&C) and/or hysterectomy, 108 single or multiple endometrial polyps were encountered and histologically analyzed., Results: A malignant transformation of polyp was found in 5 instances, meaning a rate of 4.6% i.e. 5/108: 4 cases of adenocarcinoma, 1 case of sarcoma., Discussion and Conclusion: The existence of endometrial polyps - symptomatic or not - does not seem compatible with the prolonged use of tamoxifen treatment owing the estrogen agonist potential effects of tamoxifen and its well-known hyperplastic and carcinogenic properties for the endometrium. The increased risk of endometrial cancer developing in polyps in this iatrogenic context is estimated between 2.5% and 10% in the literature.

Objective: Specify the role of axillary lymph node removal in micro-invasive in situ duct carcinomas (DCIS-MI) of the breast with a series of 107 consecutive cases., Methods: Single-centre, retrospective, anatomoclinical study with application of the European guidelines adopting as pathological definition the presence of areas of micro-invasion not exceeding 1mm. Axillary lymph node dissection was systematically complete and was preceded by the search for the sentinel node in 10 patients using the isotope method., Results: Lymph node invasion was revealed in 8 cases in the global population (7.5%). All the cases except one exhibited typical deleterious histological features: comedo architectural sub-type, high nuclear grade, and size of the lesion>3 cm. The lymph node invasion was of 18.5% in the sub-group of high-grade micro-invasive comedo-carcinomas measuring more than 3 cm., Conclusion: Contrary to those exhibiting pure DCIS, DCIS-MI patients require surgical exploration of the armpit, the most appropriate modalities of which are currently debated: classical axillary lymph node dissection or search for the sentinel lymph node; the selective lymphadenectomy procedure is not yet a consensually validated technique.

The Nottingham prognostic index (NPI), based on tumour size in breast, node involvement and Scarff-Bloom-Richardson (SBR) grading, has been shown to constitute a definitive prognostic factor of primary operable breast cancer in the adjuvant setting. We performed a retrospective study to evaluate the prognostic value of this index in 163 patients after neoadjuvant chemotherapy. Secondly, we examined the influence on survival of a revised NPI, only based on residual tumour size in breast and SBR grading in 228 patients, and consequently called breast grading index (BGI). The prognostic value of these two indices was also evaluated by replacing the SBR grade with the MSBR grade, a French modified SBR grading; the modified NPI (MNPI) and modified BGI (MBGI) were, respectively, obtained in 153 and 222 patients. At a median follow-up of 9.3 years, survival was significantly related to these four indices (P<0.001). Multivariate analysis revealed that MBGI was the only one which retained a prognostic influence on disease-free survival (P<0.02). In conclusion, the 'amount' of residual tumour in breast and/or nodes, as defined by NPI and revised indices, confers a determinant prognosis after neoadjuvant chemotherapy, inviting an alternative postsurgical treatment for a subgroup of patients with a decreased survival.

We report four cases of mixed müllerian tumors of the endometrium arising in postmenopausal women taking tamoxifen for breast carcinoma. Various histopathologic features were encountered: one müllerian adenosarcoma and three malignant mixed müllerian tumors so called carcinosarcomas (in one case the sarcomatous component was homologous composed of tissues normally found in the uterus, while the others were heterologous because they were containing some elements normally not found in the uterus). Concern has been raised about prolonged tamoxifen treatment and subsequent occurrence of endometrial adenocarcinoma. Then, attention has been drawn through high-risk histologic subtypes including poorly differentiated patterns, uterine sarcomas and such mixed müllerian tumors. There is no consensus regarding internal surveillance of women receiving tamoxifen. The usefulness of pelvic sonography has not been demonstrated.

Three surgical approaches have been described for the treatment of women presenting an endometrial cancer. The aim of this study was to appreciate the current criteria that would offer guidelines for this choice. We reviewed the data available in the literature (search Medline). Only laparotomy and laparoscopy permit the carrying out of all the routine surgical staging according to the FIGO's criteria (classification 1988). Only one randomised study compares the results obtained by laparotomy and laparoscopy. Laparoscopy patients had significantly less morbidity. Overall survival did not differ in both groups with a limited follow-up. The other not randomised studies show that laparoscopy is usually proposed to patients having a lower IMC and presenting limited stages. No randomized study had compared laparotomy with the only vaginal surgery. The latter is generally proposed for patients having an associated comorbidity and presenting limited stages. In such cases, no difference in survival is highlighted. Obesity does not represent an absolute contra indication for any way. It makes the surgery generally more complex. A suspicious ovarian lesion, a large uterus are, currently, an indication for laparotomy. Laparoscopy can be accepted only if the uterine volume is lower than 500 g and without deep myometrial infiltration. Laparotomy surgery is the standard. The main indication of vaginal surgery is to permit treatment to high operatory risk patients. Laparoscopy is an option for the early stages. It is not recommended if an ovarian lesion or a deep uterine parietal infiltration are suspected. Whatever the route used, the surgeon must be trained.

The purpose of this retrospective study was to evaluate the influence of axillary disease on patients' survival after neoadjuvant chemotherapy and to assess patient and tumor characteristics associated with post-chemotherapy axillary involvement. After six induction cycles, 277 patients with operable breast cancer (stage II-III) underwent surgery with axillary dissection, followed by radiotherapy (n = 267) or additional chemotherapy (n = 63) and adjuvant tamoxifen therapy (n = 138). At a median follow-up of 8.5 years, overall survival (OS) and disease-free survival (DFS) were analyzed as a function of node involvement. The differences in OS and DFS according to the number of positive nodes were highly statistically significant with a decreased survival associated with the increasing number of nodes (p = 5 x 10(-6) and 9 x 10(-7), respectively). Upon multivariate analysis, the node number after chemotherapy appeared as the most significant prognostic factor (p = 7 x 10(-4) for OS and p = 3 x 10(-5) for DFS). All the other classical prognostic factors were insignificant, except post-chemotherapy Scarff-Bloom-Richardson (SBR) grading for OS (p = 8 x 10(-4)) and adjuvant hormonotherapy for DFS (p = 1 x 10(-2)). Although constituting a different parameter from primary surgery data, the number of positive nodes after chemotherapy could still remain a valuable prognostic factor at secondary surgery, raising the question for high risk patients of a second non-cross-resistant adjuvant regimen, or high dose chemotherapy with peripheral blood stem cells support.

Introduction: Tamoxifen--a non steroidal triphenylethyl compound--in addition to having antiestrogenic properties may provoke weak estrogenic effects, the well known "paradoxical effects" on the female genital tractus. Concern has been raised about prolonged tamoxifen treatment and subsequent occurrence of endometrial adenocarcinoma; subsequent attention has been drawn through high risk histologic subtypes including poorly differentiated patterns and uterine sarcomas., Exegesis: We report two cases of uterine sarcoma arising in postmenopausal women taking tamoxifen, 20 mg daily during 38 and 42 months, for breast carcinoma: one leiomyosarcoma and one endometrial stromal sarcoma; both cases were asymptomatic and detected by pelvic sonography., Conclusion: Further studies will be required to establish if there is a relationship between long term tamoxifen exposure and highly aggressive types of cancer of the uterine corpus exhibiting adverse histologic features such as uterine sarcomas. There is no consensus regarding uterine surveillance of women receiving tamoxifen. We advocate an annual gynecologic examination plus imaging by means of transvaginal ultrasonography.

Introduction: Stewart-Treves syndrome has been defined by the eponymous authors as a lymphangiosarcoma in a setting of postmastectomy upper extremity lymphoedema., Exegesis: The clinical record of one patient with Stewart-Treves syndrome is analyzed. The primary angiosarcoma of the skin represented by a purple nodule occurred on a chronic lymphoedematous arm following radical mastectomy and axillary lymph node dissection for breast carcinoma performed 9 years earlier. Immunohistochemistry tests formally eliminated epithelial cutaneous metastasis and produced evidence in favour of conjunctive vascular tissue origin of the tumor., Conclusion: Conservative surgery for breast cancer, application of axillary sentinel node biopsy in the lymphatic staging and prevention of arm lymphoedema should reduce the incidence of this syndrome.

Unlabelled: Retrospective study (1985-1998) concerning surgical and histopathological features of 155 subclinical breast cancers revealed by spiculated opacity on screening mammograms., Materials and Methods: The patients were 44-78 years old (mean age, 58.5 years), 129 were postmenopausal. Preoperative localization was stereotactic in 57 instances (36.5%), sonographic in 98 instances (63.5%). Maximum tumor diameter varied from four to 25 millimeters (mean diameter 11 mm), below 10 min in 97 cases, below 5 mm in 15 cases. Axillary lymph node dissection was performed immediately (95%) or secondarily (5%)., Results: Subclinical breast tumors exhibiting spiculated picture were infiltrating carcinomas: Infiltrating ductal carcinoma (IDC) in 130 cases (84%), infiltrating lobular carcinoma (ILC) in 25 cases (16%). Not any ductal carcinoma in situ (DCIS) was detected by such an irregular opacity. The grading according to Scarff-Bloom-Richardson was used in IDC: 95 grade I (73%), 31 grade II (24%), four grade III (3%). Hormone receptor status was obtained upon 145 tumors: both estrogen receptors were present in 125 cases (86%). Axillary lymph node involvement (N+) was found in ten cases (6%), always concerning IDC > 5 mm. Conservative surgery was achieved in mort cases (97%)., Discussion: Subclinical breast cancers revealed by spiculated opacity were predominantly corresponding to infiltrating process IDC or ILC, in contrast with breast cancers revealed by microcalcifications, mainly meaning DCIS. In our experience mammographically-detected spiculated malignant tumors were not bearing unfavourable pathological or biological features: they appeared commonly well differentiated and hormonosensitive, furthermore axillary lymph nodes were rarely involved.

Objectives: To evaluate the place of ovarian transposition by laparoscopy in an effort to preserve ovarian function without compromising oncological safety among young women requiring intravaginal brachytherapy before surgery for cervical cancer., Material and Methods: The series was represented by 20 cases, all FIGO stage I squamous cell malignant diseases of the cervix. Mean age: 32 years (range 23-40). Oophoropexy (7 instances) or lateral high ovarian transposition (13 instances) was performed by laparoscopy, just before brachytherapy using cesium 137., Results: Continued hormonal function was achieved in 58% of the available cases, 50% (3/6) after oophoropexy, 68% (8/11) after ovarian transposition. Mean follow-up was 8.5 years (range 5-13). The mean radiation dose absorbed by the displaced ovary was 2.6 Gy (range 1. 2-5.9)., Conclusion: Ovarian transposition through laparoscopy before brachytherapy should be advised for selected stage I squamous type malignant tumor size 2 cm without lymphatic/vascular channel invasion by neoplastic emboli and without lymph node involvement. This procedure has been abandoned in our institution, instead of this, primary surgical treatment is accomplished (laparoscopically-assisted vaginal) radical hysterectomy is associated with orthotopic ovarian conservation.

During the past two decades, maximum cytoreductive surgery (also called debulking surgery) has been the recommended surgical approach for advanced stages of ovarian carcinoma. The residual tumor volume after surgery is one of the strongest prognostic factors, and only patients who undergo complete or optimal surgery are likely to be long-term survivors (i.e., 50% after five years). A well-trained surgeon in the field of gynecologic oncology can achieve an optimal tumor reduction in up to 75% of patients with advanced stage ovarian cancer. During the procedure, bowel resection, especially rectosigmoid, must be undertaken in 30% to 40% of cases, and para-aortic and pelvic lymphadenectomy should be performed after adequate tumor reduction in the abdominal cavity. The experienced surgeon can perform these surgeries with an acceptable morbidity, allowing chemotherapy to be undertaken within the month following surgery. However, very advanced cancer with massive peritoneal carcinomatosis and/or Stage IV disease requires a very aggressive surgical procedure but yields a poor prognosis and a higher risk of unacceptable complications. For these worst cases, the concept of cytoreductive surgery is moving toward the alternative strategy of chemosurgical cytoreduction, in which interval cytoreductive surgery is undertaken after three cycles of front-line chemotherapy. The goal of this experimental strategy is to achieve a complete tumor response after front-line chemosurgical therapy, and a better quality of life., (Copyright 2000 Wiley-Liss, Inc.)

Objectives: Assess the importance of systematic surgical exploration of the tumor focus in case of complete clinical response to neoadjuvant chemotherapy for operable breast cancer., Patients and Methods: Between 1985 and 1997, first intention chemotherapy (4 to 6 cures) was given to 433 breast cancer patients with resectable tumors measuring > or = 3 cm but who required mammectomy. Complete clinical response was observed in 112 patients (26%); 31 of them had normal mammography and ultrasound examinations (7%). Local treatment in this favorable context varied: 82 patients underwent surgery (71 conservative procedures, 11 radical procedures) and 30 patients received radiation therapy alone., Results: Complete histological response was obtained in 22 cases accounting for 6% of the entire series, 27% of the complete clinical responses, and 45% of the complete clinical and imaging responses. The incidence of local recurrence at a mean 107 month follow-up was compared between patients given complementary surgical or radiation therapy after complete clinical response. Recurrence was observed in 10 of the 82 operated patients versus 8 of the 30 nonoperated patients (12% versus 27%, NS)., Conclusion: Complete clinical response after neoadjuvant chemotherapy does not rule out the need for surgical resection of the tumor focus because the risk of neoplastic reliquats remains high (3 out of 4 cases) and because the surgical specimen provides important histological information for prognosis (in vivo chemosensitivity test). lumpectomy also contributes to reducing the risk of local recurrence.

Background: Leiomyomatosis is a benign smooth muscle tumor which can provoke serious complications in case of intracaval or intracardiac extension., Case Report: A 61-year-old woman had undergone hysterectomy at the age of 45 years for a hemorrhagic fibroma. She underwent surgery for infiltrative breast cancer 3 months before hospitalization and was taking tamoxifen 30 mg/day. In the cancer context, the diagnosis of cavo-cardiac metastatic thrombus was proposed but not confirmed at pathology. The diagnosis of uterine tissue intravascular leiomyomatosis was established on the basis of pathology findings and immunohistochemistry results., Discussion: Five other cases of leiomyomatosis after hysterectomy have been reported in the literature.

The role of axillary lymph node dissection for microinvasive ductal carcinoma in situ of the breast was analyzed in a series of 60 consecutive cases. Forty-four cases were subclinical mammographically-detected carcinomas revealed by the clusters of microcalcifications. Although pathologists differ in their criteria for microinvasion, the maximal size considered in this retrospective study was 2 mm. Axillary lymph node involvement was found in 3 cases (i.e. 5%) which harbored poor histologic features: comedocarcinoma subtype, high nuclear grade, and size of the ductal carcinoma in situ greater than 3 cm, requiring total mastectomy. While there is no need for axillary dissection in women with pure ductal carcinoma in situ, the management is quite different in proven microinvasion. Owing to the weakness of prognostic information given by cellular, biochemical and molecular features, instead of lymph node status, axillary dissection is still recommended in microinvasive ductal carcinoma in situ.

Objective: To assess the characteristic features of ovarian carcinoma mucocellular secondary to breast cancer., Methods: A retrospective pathology evaluation of ovariectomy specimens was conducted to compare the histological types with the original pathology diagnosis of breast cancer., Results: Ten cases of ovarian carcinoma mucocellular were observed. Histologically, the ovarian stroma presented voluminous mucin-containing vacuoles in epitheliomatous cells with peripheralized nuclei. In 7 out of 10 cases, the primary breast cancer was invasive lobular carcinoma., Discussion: These pathology findings are in agreement with comparative studies on the metastatic behavior of different histological types of breast cancer: invasive lobular carcinoma differs from invasive ductal carcinoma by its tropism for gastrointestinal and internal genital organs.

We report 6 cases of tuberculous peritonitis, focusing on the contribution of laparoscopic exploration. The initial diagnosis was erroneus in all cases: the polymorphous clinical presentations suggested another infectious disease or cancer disease. Laparoscopy was performed in 5 patients who had ascitis and in 1 with plastic peritonitis. At laparoscopy, the peritoneum showed miliary granulations and inflammatory adherences on the visceral or parietal sheats. Bacteriological analyses of the ascitic fluid were positive in only one case. The diagnosis was confirmed after culture of biopsy specimens and identification of the Kock bacilli or on the basis of objective evidence of an epithelioid giant-cell granuloma with caseous necrosis. Outcome was favorable after appropriate antibiotic therapy.

Epithelial ovarian cancer is usually diagnosed at an advanced stage with a bulky tumor in the pelvis and upper abdomen. The most common therapeutic strategy begins by a surgical operation that allows histologic diagnosis, accurate staging and maximal debulking. Since the papers by Griffiths at the end of the seventies, the volume of the residual tumor after surgery appears to be one of the most important prognostic factors in all series. Indeed, patients whose tumor is completely or optimally debulked have greater chances of prolonged survival of about 50% at 5 years. Surgeons experienced in this field can achieve optimal debulking in about 75 to 80% of cases. But, in order to reach this objective, they must often perform an ultra-radical operation with extensive peritonectomies, lymphadenectomies and intestinal resections. Moreover, since 1983, Hacker has shown that the initial tumor bulk was still a poor prognostic factor even after debulking. Today it can be demonstrated that the greater the tumor bulk the more aggressive must be the surgical procedure in order to be optimal and the final benefit will nevertheless be proportionally lower with a higher morbidity rate. This paradigm leads the surgeons to currently try to more accurately assess the initial tumor bulk in order to determine wether the tumor would be optimally debulked by means of a well-standardised operation. If not, the alternative strategy would be 3 chemotherapy courses as front-line treatment before debulking surgery, which hopefully would be easier. Trials are needed in order to validate this strategy despite the fact that some patients will unfortunately have their prognosis jeopardized by the chemoresistance of their tumor.

We report a study of 41 radical hysterectomies performed through laparoscopic approach for carcinoma of the cervix uteri. According to the FIGO staging, the tumors were classified as 12 stages Ia2, 24 stages Ib, 4 stages IIa and 1 stage IIb. 17 patients were treated by exclusive surgical procedure. 24 patients received a combination of radiation therapy and surgery 2 patients had a tumor of the cervical stump after subtotal hysterectomy. The mean duration of the procedure was 270 minutes. The post-op stay was 6.5 days. There was no major operative and postoperative complication. Only one patient required a blood transfusion. The intravenous pyelogram control was correct in all cases. At this time, with a 4 to 76 months follow-up, no recurrence was observed. This experience suggests the faisability of the laparoscopic radical hysterectomy. This approach seems to be convenient in young and non obese women with a tumor less than 4 cm in the greatest diameter.

We report the case of 68-year-old woman with an adenocarcinoma of the right colon. The family history also suggested that she might also be at risk of ovarian or endometrial cancer. Thus despite the lack of gynecologic symptoms, abdominal hysterectomy and bilateral salpingo-oophorectomy was proposed at the time of the right colectomy endometrial carcinoma was discovered at surgery. This finding and the family pedigree were consistent with the diagnosis of familial Lynch II syndrome. Appropriate biomolecular analyses were undertaken. This case shows the importance of family history taking in patients with cancer. The surgeon should be aware of such situations and correlate indications and procedures with the genetic risk of the patients.

Objective: To study fertility of patients with adnexal abscesses treated by laparoscopy, antibiotic therapy, and second-look laparoscopy., Design: A retrospective clinical study., Setting: Department of Obstetrics Gynecology and Reproductive Medicine, University of Auvergne, University Hospital of Clermont Ferrand, France., Patient(s): Thirty-nine patients treated for adnexal abscesses between January 1983 and December 1992., Intervention(s): Laparoscopic drainage of adnexal abscesses was performed in all patients; 35 patients underwent a second laparoscopy 3 to 6 months later., Main Outcome Measure(s): Immediate and long-term clinical results, anatomical data obtained at second-look laparoscopy, spontaneous fertility., Result(s): No immediate reoperation was necessary within the first 2 months after the initial laparoscopic surgery. At second-look laparoscopy, an adhesiolysis was necessary in all cases. A distal tuboplasty was performed in 17 patients and 6 patients were referred to IVF-ET. Subsequently, 12 of 19 patients not using any contraception obtained a spontaneous intrauterine pregnancy (63%)., Conclusion(s): This study confirms that laparoscopic surgery is a safe and efficient technique for treating adnexal abscesses. Anatomical results observed at second-look laparoscopy suggest that this second surgical step is essential for patients desiring future pregnancy.

The study concerns 265 patients with axillary lymph node dissection for non-palpable breast cancer. The mammographically detected breast tumors were: 36 ductal carcinomas in situ (DCIS), 23 microinvasive carcinomas, 206 invasive carcinomas of which 179 were invasive ductal cancers (IDC), 25 invasive lobular cancers (ILC) and 2 mucinous invasive carcinomas. The histologic size of the invasive component was < or = 5 mm in 38 cases, 6-10 mm in 84 cases, 11-15 mm in 53 cases, 16-20 mm in 16 cases, > 20 mm in 15 cases. Axillary dissection was performed immediately during the initial surgical procedure in 209 patients (79%) or secondarily in 56 (21%) according to the results of intraoperative examination of surgical specimens on frozen sections. Axillary lymph node involvement was not found in DCIS, microinvasive carcinomas or invasive carcinomas < or = 5 mm in size. Among all 206 invasive breast carcinomas, lymph node involvement was found in 7.8% (16/206) of cases. There were 9/84 (10.7%) in tumors > 10 mm, 7/122 (5.8%) in tumors < or = 10 mm. Thus, it is concluded that lymph node involvement is unlikely to be found in patients with non palpable breast cancers, specially those with carcinoma in situ, microinvasive breast tumors and invasive breast cancer with less than 5 mm maximum diameter size. Axillary dissection may be avoided in these patients. However, the use of new prognostic factors of lymph node involvement may help in the definition of patient group.

Tamoxifen, a non-steroid anti-oestrogen derivative of diethylstilboestrol, is the main drug used for hormone therapy for hormone-dependent breast cancer. This ambivalent drug has both antagonist and agonist effects. While tamoxifen blocks tumour growth it can also have an undesirable agonist effect on the genital tract. The uterus is a target organ for this paradoxical action due to proestrogenic stimulation of the endometrium and the myometrium. We observed eleven cases of uterine fibromyoma during treatment with tamoxifen which required hysterectomy due to increased tumour volume. The pathology report on the surgical specimens did not show any evidence of malignancy. Differential diagnosis is based on sarcomatous degeneration of the fibromyoma and presence of intra-myomatous metastases from the breast. Hysterectomy is indicated in menopaused patients with a symptomatic fibromyomatous uterus before starting long-term anti-oestrogen therapy for hormone-dependent breast cancer.

Incisional hernia occurred in a patient after laparoscopic hysterectomy. The greater omentum was incarcerated in the tract of the suprapubic trocar (12 mm diameter). Diagnosis and treatment were performed during a second laparoscopy procedure. The greater number of trocar instruments and their larger diameter increases the risk of parietal morbidity after laparoscopic procedures. Elective closures of trocar incisions is recommended when exceeding 10 mm. Prevention of extra-umbilical incisional hernias and dehiscences appears to be more effective when suture is performed under laparoscopic vision with the trocar inserted. Both the aponevrosis and the peritoneal membrane should be treated.

Two women (63 and 68 years) presented with primary angiosarcomas of the skin which had developed on an area of chronic lymphoedema after radiosurgical treatment for breast cancer 4 and 13 years earlier. Immunohistochemistry tests formally eliminated epithelial metastasis and produced evidence in favour of lymphatic or capillary vascular proliferation. Endothelial affinity for anti-factor VIII and positive tests for certain markers of intermediary filaments (actin, vimentin) confirmed the vascular and conjunctive tissue origin of the tumours.

Three rare cases of tumours of the cervix are reported: embryonal rhabdomyosarcoma, granulocyte sarcoma and lymphoma. There were particular problems with diagnosis in each case requiring histochemistry, immunohistochemistry and ultrastructure examinations. Embryonal rhabdomyosarcoma is a uncommon tumour in the adult. Clinically, there is a vegetative formation but no botryoid aspect. Striated muscle cell proliferation, suggested by the morphology of the malignant cells was confirmed by immunohistochemistry which demonstrated desmine and vimentine and by the ultrastructural study which demonstrated Z lines in the cytoplasm of the malignant cells. Granulocyte sarcoma is characterized by a non-tumoural non-destructive infiltration of inflammatory-like cells. Their granulocyte nature is confirmed by histochemistry, the Leder's reaction on frozen samples, immunohistochemistry (expression of NP57). Electron microscopy can also be used. The diagnosis of lymphoma is difficult due to the non-tumoural nature of the lymphomatous infiltration which can simulate inflammatory reaction. In our case, the diagnosis was made on the tumoural aspect of the biopsy made in the deep infiltration zone of an adjacent organ (bladder). Immunohistochemistry demonstrated the lymphoid nature of the tumour and identified a B phenotype. The ultrastructural study gave little information.

Vaginal ultrasonography of the uterus using a high frequency endocavitary probe was performed in 300 postmenopausal women: 150 receiving no replacement nor suppressive hormone therapy and 150 receiving adjuvant anti-estrogen treatment in the form of tamoxifen because of breast cancer. Evidence was found of hydrometra in 84 cases (28%): 10 in the group taking no hormone therapy (6.6%) as compared with 74 in the group exposed to tamoxifen (49.3%). The difference was statistically significant (p < 0.01). In addition, mean thickness of the endometrium was estimated at 6 mm (range: 2-40) in the first group versus 12 mm (range: 3-60) in the second (p < 0.001). It emerged from this comparative ultrasound study that the incidence of postmenopausal hydrometra was influenced by taking tamoxifen. Fluid secretion appearances seen one out of two in treated patients reflect the paradoxical proestrogenic type action of tamoxifen on the uterine mucosa.

The authors report their experience of the use of a latissimus dorsi myocutaneous flap in reparative surgery after total or partial mastectomy for invasive breast cancer. The series, including 101 cases, was separated into four groups on the basis of the context: I--thoracic radionecrosis (5 cases); II--chest wall cover (24 cases); III--immediate breast reconstruction (57 cases); deferred breast reconstruction (15 cases). The well-known vascular reliability of this pediculated flap was confirmed here by the low incidence of necrosis (3%), always marginal. Other complications were not attributable to the flap itself but to concomitant radiodystrophic skin lesions and the presence of the prosthetic implant in the case of breast reconstruction.

The authors report their experience with immediate breast reconstruction following salvage mastectomy for local recurrence of invasive breast cancer after conservative treatment. From January 1987 to December 1992, among 91 immediate breast reconstructions, 41 were performed for this indication. The results and complications were analyzed for each of the three techniques used: simple prosthesis (n = 5), latissimus dorsi flap with prosthesis (n = 26), trans abdominalis musculocutaneous flap--TRAM flap (n = 10). Immediate flap reconstruction appears to be required in cases of either early or late local relapse since the skin has been irradiated and the mastectomy must be extensive. The transrectus abdominalis flap allows more extensive resection and gives better cosmetic results without the need for a prosthesis.

A retrospective series of 34 cases of breast cancer combined with uterine cancer is reported. Cancers of the endometrium differed from cervical cancers by their number, 2.2 x more frequent (22 vs 10) and by the sequence of onset: they generally precede breast cancer, whereas they tend to follow cervical cancers. In contrast to the breast cancer/uterine cervical cancer association, which is considered to be fortuitous, the breast cancer/cancer of the uterine body association appears to be determined by a hormonal context. Through a review of the literature, a unifying endocrine theory is constructed, based on the role of hyperestrogenesis in mammary and endometrial carcinogenesis.

The authors report a case of an ovarian abscess presenting as acute sciatica with pyrexia in a 36-years-old woman with an intrauterine contraceptive device. Imaging (plain X-ray of abdomen and CT scan) was clear-cut, showing an air pocket as a result of abscess formation and dental calcifications which enabled a preoperative diagnosis of dermoid cyst. The outcome was successful following appropriate surgical treatment and unilateral tubo-oophorectomy.

The authors report a retrospective series of 32 patients who were operated on by resection of bowel at various stages during the progress of epithelial pathology of malignant ovaries. These operations were carried out in one group during the initial operation, in a second group during a "second-look" operation and in a third group when late recurrences had occurred. Removal of bowel was possible to remove completely or to optimum effect malignant cell bearing areas in 22 cases (59%) and less than optimal reductions in 15 cases (41%). Forty-five different segments of bowel were resected consisting of 18 of the rectum and sigmoid, 11 of the right side of the colon, 9 transverse or left colon, and 5 of the small intestine and 2 of the stomach. One patient died from cardio-respiratory failure immediately after the operation. Seven cases had septic abdominal complications but they settled quickly without further surgery. It was not possible on studying the follow-up of these patients to find any statistically significant improvement in those who had complete or optimum resection as compared with those who were less completely operated on, and those who were operated on in a late stage of the illness. All the same even if it is not possible to show that there is a significant improvement in survival in the populations that have been compared in this study, it does seem advisable to practice bowel resection in order to reduce as much as possible cancer bearing cells so that chemotherapy can be applied more effectively and thus improve the prognosis.(ABSTRACT TRUNCATED AT 250 WORDS)