Search

Background The impact of the first coronavirus disease 2019 (COVID-19) wave on cancer patient management was measured within the nationwide network of the Unicancer comprehensive cancer centers in France. Patients and methods The number of patients diagnosed and treated within 17 of the 18 Unicancer centers was collected in 2020 and compared with that during the same periods between 2016 and 2019. Unicancer centers treat close to 20% of cancer patients in France yearly. The reduction in the number of patients attending the Unicancer centers was analyzed per regions and cancer types. The impact of delayed care on cancer-related deaths was calculated based on different hypotheses. Results A 6.8% decrease in patients managed within Unicancer in the first 7 months of 2020 versus 2019 was observed. This reduction reached 21% during April and May, and was not compensated in June and July, nor later until November 2020. This reduction was observed only for newly diagnosed patients, while the clinical activity for previously diagnosed patients increased by 4% similar to previous years. The reduction was more pronounced in women, in breast and prostate cancers, and for patients without metastasis. Using an estimated hazard ratio of 1.06 per month of delay in diagnosis and treatment of new patients, we calculated that the delays observed in the 5-month period from March to July 2020 may result in an excess mortality due to cancer of 1000-6000 patients in coming years. Conclusions In this study, the delays in cancer patient management were observed only for newly diagnosed patients, more frequently in women, for breast cancer, prostate cancer, and nonmetastatic cancers. These delays may result is an excess risk of cancer-related deaths in the coming years., Highlights • A reduction of the number of cancer patients attending cancer centers was observed in France from January to July 2020. • This reduction was observed only for newly diagnosed patients. • The reduction of new diagnosis was more pronounced in women, for breast cancer, and prostate cancer, and nonmetastatic cancer. • No compensation was observed for the last months of 2020. The magnitude of delays may be larger in centers within the same country. • An estimation of the excess cancer death resulting from these delays is presented.

GANEA2 study was designed to assess accuracy and safety of sentinel lymph node (SLN) after neo-adjuvant chemotherapy (NAC) in breast cancer patients. Early breast cancer patients treated with NAC were included. Before NAC, patients with cytologically proven node involvement were allocated into the pN1 group, other patient were allocated into the cN0 group. After NAC, pN1 group patients underwent SLN and axillary lymph node dissection (ALND); cN0 group patients underwent SLN and ALND only in case of mapping failure or SLN involvement. The main endpoint was SLN false negative rate (FNR). Secondary endpoints were predictive factors for remaining positive ALND and survival of patients treated with SLN alone. From 2010 to 2014, 957 patients were included. Among the 419 patients from the cN0 group treated with SLN alone, one axillary relapse occurred during the follow-up. Among pN1 group patients, with successful mapping, 103 had a negative SLN. The FNR was 11.9% (95% CI 7.3–17.9%). Multivariate analysis showed that residual breast tumor size after NAC ≥ 5 mm and lympho-vascular invasion remained independent predictors for involved ALND. For patients with initially involved node, with negative SLN after NAC, no lympho-vascular invasion and a remaining breast tumor size 5 mm, the risk of a positive ALND is 3.7% regardless the number of SLN removed. In patients with no initial node involvement, negative SLN after NAC allows to safely avoid an ALND. Residual breast tumor and lympho-vascular invasion after NAC allow identifying patients with initially involved node with a low risk of ALND involvement.

Background Half of the patient treated with neoadjuvant chemotherapy (NAC) for a large operable breast cancer has no axillary lymph node involvement at the time of surgery. Sentinel lymph node detection (SLND), after NAC, is aimed to select patient who should be safely spared of an axillary lymphadenectomy (ALND).GANEA 2 is a French prospective multi institutional trial, aimed to assess SLND after NAC. Objective To assess the risk of relapse for patients without previous axillary node involvement treated with NAC followed with a SLND without a systematic lymphadenectomy. Patients and Method Inclusion: FIGO stage T1-T3 infiltrating breast carcinoma, indication of NAC. Exclusion: inflammatory cancer, local relapse, contra-indication to NAC, NAC interrupted due to progressive disease. Design: indication to plan a NAC, axillary sonography with fine needle cytology before NAC to select patients without lymph node involvement, SLND after NAC. ALND was mandatory in case of SLN involvement (macro or micro-metastasis) or SLND failure. Follow-up was scheduled with a medical visit / 6 months with axillary assessment and a mammography each year. Follow-up results are updated every 6 months. Pathological analysis were carried out according to standard methods and classified according to the last American Joint Committee staging system. Studied parameters were SLND detection rate, pathological results on breast specimen and nodes, rate of relapse (axilla, breast, metastasis), and survival. Results From July 2010 to February 2014, 587 patients were enrolled, from 17 institutions, and experienced breast tumor surgery and a SLND after NAC. Each patient experienced breast surgery. A breast tumour pathological complete response was found in 21.3% (125/587). SLND rate was 97% (570/587), with a median number of 2 sentinel nodes (1-9). Patients with a sentinel detection failure (n=17) experienced a systematic lymphadenectomy, without any involvement (n=13), a micro-metastasis (n=2) and a macro-metastasis (n=2). A total of 140 patients had at least one sentinel node involved: macro-metastasis (n=86), micro-metastasis (n=54). A lymphadenectomy was performed in 128 cases: metastasis free (n=100), macro-metastasis (n=17), micro-metastasis (n=11). A total of 430 patients had a SLN metastasis free (75% ;430/570). A not mandatory lymphadenectomy was performed (n=14): metastasis free (n=11), macro-metastasis (n=2) and micro-metastasis (n=1). 17 patients were lost to follow-up. A total of 399 patients without sentinel node involvement were followed 2.3 years (from 0.5 to 5.6 yrs). At 3 years overall survival was 97.8% [94.9-99.1], disease free survival was 94.8% [91.0-97.1%]. Six patients died. Fifteen patients experienced a relapse: 8 metastasis, 4 homolateral breast, 2 controlateral breast, 1 homolateral axillary relapse. Conclusion This is the most important series of patients followed 2.3 years after SLND without axillary lymphadenectomy after NAC for an advanced breast cancer, showing acceptable results. The current series validate the safety of this conservative strategies avoiding systematic lymphadenectomy to patients without initially involved axillary node treated with NAC. Citation Format: Classe J-M, Loaec C, Alran S, Paillocher N, Tunon-Lara C, Gimbergues P, Faure-Virelizier C, Chauvet M-P, Lasry S, Dupre P-F, Verhaeghe J-L, De Blaye P, Gutowski M, Barranger E, Lecuru F, Lefevre Lacoeuille C, Loussert L, Lambaudie E, Ferron G, Campion L. Sentinel node detection after neoadjuvant chemotherapy in patient without previous axillary node involvement (GANEA 2 trial): Follow-up of a prospective multi-institutional cohort [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr S2-07.

Introduction : The harvest of the latissimus dorsi muscle for the realization of immediate breast reconstruction induces a large dorsal scar measuring up to 20 centimeters, while only the muscle is used. We present here the results of our experience of endoscopic harvesting of the latissimus dorsi muscle using 3D technology. Our main objective is to reduce the dorsal scar and second assess the functional consequences for patients. Methods: Between December 1st, 2015 , and June 1st, 2016, there were 7 patients who underwent latissimus dorsi endoscopic harvesting, with 3D technology, for an immediate breast reconstruction after a skin-sparing or nipple sparing mastectomy. Results: 4 patients had latissimus dorsi muscle with breast implant and 3 patients by latissimus dorsi muscle only. The age average was 55 years (range 45-70). The mean length of surgery was 250 minutes (range 150- 380). The mean length of hospitalization was 7 days (range 4-12 days). One patient treated for local recurrence had skin necrosis because of previous radiotherapy. Donor site seroma was the main post surgery drawback. Patients on average benefited from 3 evacuations (range 1-5) of 850ml (range 640-1270ml). Acceptance of the reconstructed breast was good in six cases, and poor in one case. Only one patient reported discomfort at the donor site 1 month after surgery. Conclusion: The endoscopic 3D latissimus dorsi flap harvesting allows to reduce donor site scar. There is no significant difference concerning complications or post-operative pain and functional discomfort between the endoscopic and classic harvesting procedure. Citation Format: Barranger E, Dejode M. Endoscopic 3D latissimus dorsi muscle harvesting for immediate breast reconstruction. Results of our 7 patients experience in Antoine Lacassagne Nice Cancer Center [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-14-14.

Introduction/Background In SOLO1 trial, maintenance therapy with olaparib considerably improved progression-free survival (PFS) among women with newly-diagnosed, advanced BRCA-mutated HGEOC. Based on the large real-life ESME ovarian cancer (OC) cohort, we aimed to describe the patient‘s characteristics and survival outcomes of a selected cohort of BRCA-mutated patients before the era of PARP inhibitors maintenance in first line. Methodology ESME OC is a national cohort including all patients (pts) with EOC managed in the 18 French Comprehensive Cancer Centres (NCT03275298). ESME Research program collected retrospective data from patient‘s medical records. BRCA1, BRCA2, or both mutated patients with de novo diagnosed advanced (FIGO stage III or IV) high-grade serous or endometrioid EOC were eligible. Primary objective was to describe patient‘s characteristics, clinical features and treatment patterns. Results Of the 4777 patients with OC treated in first line by platinum-based chemotherapy between 2011 and 2016, 266 were included. Median age was 57.0 (33–81). 187 pts (70.3%) harbored a BRCA1 mutation, and 75 (28.2%) a BRCA2 mutation. 66.9% of patients had FIGO stage III disease. Almost all patients (95.5%) underwent surgical resection, after neoadjuvant chemotherapy (48%), or primary debulking surgery (44.9%). 119 pts (44.7%) received maintenance therapy and majority with bevacizumab alone (78.9%). After a median follow-up of 51.7months, the median PFS (mPFS) was 28.6months [95 CI: 26.2–32.4]. Patients exhibited higher mPFS in case of FIGO stage III than stage IV (32.4 months and 25.4 months, respectively), or BRCA2 mutation than BRCA1 (33.3 months and 27.7 months, respectively). Although populations were non comparable, mPFS was close between patients treated with or without maintenance (28.3 and 29.5 months, respectively). Median PFS2 were 51.4 months and 50.4 months, respectively. Estimated 5-year OS for the whole population was 69.2% [95 CI: 65.3–73.0]. Conclusion This large ESME OC cohort described clinical features and real-life survival outcomes among pts with newly diagnosed advanced BRCA-mutated HGEOC treated in specialized centres. Disclosure This work was supported by UNICANCER. The ESME OC database is supported by an industrial consortium (Roche, Pfizer, AstraZeneca, MSD, Eisai and Daiichi Sankyo). Data collection, analyses and publications are totally managed by R&D UNICANCER independently of the industrial consortium. All the authors declare that there is no conflict of interest regarding the publication of this article.

The sentinel node procedure (GS) is the recommended technique for axillary surgical exploration in localized breast cancer with no clinical or radiological lymph node involvement. This surgical technique is based on a dual isotope and colorimetric detection. Although it allows a significant reduction in morbidity compared to axillary dissection (CA), this procedure induces a number of organizational constraints, in particular for the radioisotope injection. Specially for this reason, other GS methods have emerged in recent years, some of which appear promising (detection by fluorescence and magnetic iron). The objective of this paper was to carry out a synthesis of the reference method of detection (radioisotope) GS and analyze the recent literature on new detection methods.

PurposeTo prospectively determine the range of abdominopelvic ultrasonographic findings, including Doppler resistance index (RI) of uterine arteries, 2 and 24hours after uncomplicated delivery.MethodWomen who delivered vaginally or after cesarean section without complication from January 2012 to April 2012 in a tertiary care hospital were prospectively included. Abdominopelvic ultrasonography, including uterine artery resistance index (RI) at duplex Doppler ultrasonography, was performed 2hours and 24hours after delivery.ResultsNinety-two women (mean age, 32.7 years) were included. Sixty-one (66%) delivered vaginally and 31 (34%) had cesarean section. Twenty-four hours after vaginal delivery, endometrial and anterior wall thicknesses dropped and uterine width increased (P

Background To define a core set of geriatric data to be methodically collected in clinical cancer trials of older adults, enabling comparison across trials. Patients and methods Following a consensus approach, a panel of 14 geriatricians from oncology clinics identified seven domains of importance in geriatric assessment. Based on the international recommendations, geriatricians selected the mostly commonly used tools/items for geriatric assessment by domain (January–October 2015). The Geriatric Core Dataset (G-CODE) was progressively developed according to RAND appropriateness ratings and feedback during three successive Delphi rounds (July–September 2016). The face validity of the G-CODE was assessed with two large panels of health professionals (55 national and 42 international experts) involved both in clinical practice and cancer trials (March–September 2017). Results and discussion After the last Delphi round, the tools/items proposed for the G-CODE were the following: (1) social assessment: living alone or support requested to stay at home; (2) functional autonomy: Activities of Daily Living (ADL) questionnaire and short instrumental ADL questionnaire; (3) mobility: Timed Up and Go test; (4) nutrition: weight loss during the past 6 months and body mass index; (5) cognition: Mini-Cog test; (6) mood: mini-Geriatric Depression Scale and (7) comorbidity: updated Charlson Comorbidity Index. More than 70% of national experts (42 from 20 cities) and international experts (31 from 13 countries) participated. National and international surveys showed good acceptability of the G-CODE. Specific points discussed included age-year cut-off, threshold of each tool/item and information about social support, but no additional item was proposed. Conclusion We achieved formal consensus on a set of geriatric data to be collected in cancer trials of older patients. The dissemination and prospective use of the G-CODE is needed to assess its utility.

The sentinel lymph node (SLN) is a standard for the surgical treatment of axillary localized breast cancer N0. It is based on a double isotopic and color detection. With a gamma detecting probe connected to an infrared camera, Declipse SPECT system (Surgiceye(®)) is able to detect and locate any radioactive source in 3D. Mobile character for use in the operating room is particularly interesting for the intraoperative detection of SLN. We illustrate its usefulness in a clinical case where the preoperative identification of SLN by lymphoscintigraphy was not informative.

Gynecologie Obstetrique & Fertilite - Sous presse. Epreuves corrigees par l'auteur. Disponible en ligne depuis le samedi 21 mai 2016

Resume Objectif Evaluer l’effet lymphostatique du combipatch TachoSil® dans la prevention des lymphoceles apres curage axillaire dans le cancer du sein localise. Patientes et methodes Etude retrospective, cas–temoin, realisee entre janvier 2007 et decembre 2009, dans deux services de gynecologie-obstetrique de l’AP–HP. Soixante-six patientes (45 dans le groupe temoin et 22 dans le groupe TachoSil®) ayant subi un curage axillaire seul, avec mise en place d’un redon ou associe a une tumorectomie, ont ete incluses. La quantite totale de lymphe drainee durant le sejour, le nombre de jours de drainage, la duree d’hospitalisation, le nombre de lymphoceles et le nombre de ponctions realisees au decours de l’hospitalisation ont ete recueillis. Resultats La population etait similaire concernant l’âge, l’indice de masse corporelle (IMC), les donnees cliniques et anatomopathologiques. Il n’existait pas de difference significative en termes de volume total de lymphe draine (268,2 ± 220,7 mL sans TachoSil® et 228,6 ± 128,8 mL avec TachoSil®, p = 0,89) et le nombre de jours de drainage (3,9 ± 1,6 j sans TachoSil® et 3,1 ± 0,9 j avec TachoSil®, p = 0,10). Par contre, la duree d’hospitalisation etait significativement plus elevee dans le groupe TachoSil® (5 ± 1,6 j avec TachoSil® et 3,8 ± 1,1 j sans TachoSil®, p = 0,006). Conclusion Cette etude ne demontre pas de benefice du combipatch (TachoSil®) dans la prevention des lymphoceles apres curage axillaire. Une etude randomisee avec de grands effectifs est desormais necessaire.

Background: The aim of this study was to compare clinical and pathological outcomes after neoadjuvant chemotherapy between oestrogen receptor (ER)-positive invasive pure lobular carcinoma (ILC) and invasive ductal carcinoma (IDC). Methods: This analysis included 1895 patients (n=177 ILC; n=1718 IDC), with stage I–III breast cancer, who received neoadjuvant chemotherapy. Clinical and pathological response rates, the frequency of positive surgical margins and rate of breast-conserving surgery were compared. Results: There was a trend for fewer good clinical responses in ILC compared with IDC. Tumour downstaging was significantly less frequent in ILC. Positive or close surgical resection margins were more frequent in ILC, and breast-conserving surgery was less common (P

Abnormal placental invasion can result in major obstetric haemorrhage during delivery. The most important risk factors are the following: previous caesarean delivery, placenta praevia maternal age over 35, smoking, previous myomectomy, dilatation and curettage. When placenta accreta is suspected on ultrasound, an RMI can complete the diagnostic. Therefore, patients must be managed, as far as possible, in a reference centre, by a trained medical team. Birth must be planned in order to decrease complications rate. Treatment can consist in radical management (caesarean-hysterectomy) or conservative management (preservation of both uterus and placenta). Conservative management allows patients to keep fertility but can also decrease blood loss during delivery. Side effects of this therapy are secondary haemorrhage, sepsis, long-term follow-up and vaginal loss. There are few studies describing fertility after conservative management, but it seems to be a secure treatment for future pregnancies. Embolization can be a very useful, already demonstrated, help when massive haemorrhage occurs. Management of placenta accreta is multidisciplinary and patients must be informed of all options. Treatment is decided regarding history of the patients, operative findings and peri-partum blood loss.

Non-palpable breast cancers are more and more frequent. Their surgical management requires the excision of the tumor and sentinel lymph node (SLN) needing a technical preoperative organization combining preoperative identification of the tumor by wire guide and injection of a radioactive tracer for the identification of SLN. The implementation of this minimally invasive surgery is sometimes paradoxically complicated due to the presurgical organization requiring several medical teams. It is for this reason that hand-held gamma-cameras have been developed, used either preoperatively or during surgery to replace lymphoscintigraphy but also as a help to excision of the tumor after radioisotope injection. The objective of this study was to evaluate the interest of the main hand-held gamma-cameras used in breast cancer.

The quality of surgical margins in lumpectomy are strong criteria to define risk of locoregional recurrence when conservative treatment is undertaken. Intraoperatively, the limits of adequate resection are sometimes difficult to define. This is why some teams propose the realization of systematic cavity margins during the excision of lumpectomy during the same operation. We expose the potential benefits of this type of practice using data from the literature.

The development of conservative surgical approaches and interventionnal radiology for conservative treatment in cases of severe post-partum haemorrhage allows nowadays a preservation of the genital tract in most of the cases in developed countries. The consequences of these techniques for the future fertility and pregnancy outcome are not fully evaluated. Very few cases of infertility are reported and the majority of the patients seem to recover regular menstrual menses after application of any of the described conservative approach. Pregnancy outcomes appear unchanged without any consequence concerning foetal growth. However, complications might occur, impairing future fertility or pregnancy outcome: uterine synechia have been described after arterial embolization, ovarian failures occurred after stepwise surgical approach including lombo-ovarian artery ligature, synechia and uterine infection impaired uterine compression sutures. Furthermore, recurrence of post-partum haemorrhage and abnormal placentation rates seem to be higher for future pregnancies.

Resume Objectif L’hemorragie du post-partum (HPP) est la principale cause de mortalite maternelle et est responsable en France chaque annee d’un quart des deces maternels. Nous avons realise un etat des lieux des transferts pour HPP en 2008 et 2009 dans un centre de reference (hopital Lariboisiere). Patientes et methodes Il s’agit d’une etude retrospective descriptive sur une periode de deux ans, incluant toutes les patientes prises en charge pour une hemorragie de la delivrance. Resultats Deux cent quatre-vingt-dix-neuf patientes ont ete prises en charge pour une HPP en 2008 et 2009 a l’hopital Lariboisiere. Parmi les patientes transferees, l’âge moyen des patientes etait de 30,9 ans avec des extremes variant de 16 a 43 ans. Il s’agissait de patientes primipares (45,4 %), ayant accouche de singletons (90,3 %) par voie naturelle dans 63,8 % des cas. La prise en charge a l’arrivee a Lariboisiere reposait sur une surveillance en salle de reveil dans 71,4 % des cas. Le taux d’embolisation etait de 22,4 %. Discussion et conclusion Une surveillance en salle de reveil associee a des mesures de reanimation et a l’utilisation de prostaglandines est le plus souvent suffisante pour la plupart des prises en charge des HPP. En cas d’hemorragie persistante, l’embolisation reste une excellente option therapeutique et une bonne alternative a l’hysterectomie d’hemostase, qui doit cependant garder sa place dans certaines HPP severes.

Sentinel lymph node (SLN) mapping and biopsy have emerged as the technique of choice for axillary staging of breast cancer. Several methods have been developed to identify SLNs, including peritumoral or periareolar injection of blue dye or technetium colloid. The optimal site for injection of mapping tracers is controversial in SLN. The peritumoral injection provides information on the deep lymphatic drainage and the internal mammary chain. The advantages of periareolar injection are simplicity, the ability to perform it in non-palpable tumors, and the potential enhancement of uptake via the subareolar lymphatic plexus. The results of multiinstitutional study have indicated that superficial injection (periareolar or peritumoral) is associated with a better identification rate and an equal false-negative rate compared to deep peritumoral (PT) injection. However, the false-negative rate of periareolar injection has not been formally demonstrated.

In cases of serious bleeding postpartum, resuscitation and surgical techniques are complementary and should be adapted to both the etiology and severity of bleeding. In extremely severe cases, the performance of a hysterectomy should not be delayed. For women with stable hemodynamic status, so-called "conservative" surgical techniques can instead be used. In this study, we describe and discuss the indications and feasibility of various techniques of vascular ligation. Uterine mattress suture compression techniques and abdomino-pelvic packing are also described. When conservative management is feasible, the first line approach should be bilateral distal ligation of the uterine arteries: this simple and low-risk technique is immediately effective in 80% of cases. If bleeding persists, uterine devascularization can be completed by a triple ligation as described by Tsirulnikov, with or without supplemental proximal ligation of the uterine arteries. This procedure should be performed in preference to the so-called "stepwise ligation sequence", which involves ligation of the ovarian pedicles and poses a risk of subsequent ovarian failure. Bilateral hypogastric artery ligation is also an effective and widely used first-line technique for experienced surgeons. This approach is technically challenging for less-experienced surgeons and is reserved for cases of failed triple ligation.

Resume Objectifs Evaluer les complications maternelles et fœtales des extractions instrumentales par ventouse Kiwi ® par rapport aux forceps et spatules. Patientes et methodes Les patientes ayant beneficie d’une extraction instrumentale entre le 2 novembre 2006 et le 30 avril 2007 ont ete incluses dans cette etude retrospective unicentrique. Nous avons compare les complications survenant apres extraction par ventouse Kiwi ® a celles survenant avec les autres instruments. Resultats Cent soixante-neuf patientes ont ete incluses, dont 79 ont beneficie d’une extraction par ventouse Kiwi ® . Les deux populations (extraction par ventouse et autres instruments) etaient comparables sur le plan des caracteristiques maternelles, du deroulement du travail et des conditions de realisation de l’extraction instrumentale. Le taux d’episiotomie etait significativement moins eleve en cas d’extraction par ventouse (73,1 % versus 94,4 % ; p = 0,0001), ainsi que le taux d’hemorragie du postpartum (8,9 % versus 18,9 % ; p = 0,04). Aucune dechirure du deuxieme ou troisieme degre n’etait rapportee en cas d’extraction par ventouse. Le taux de difficulte aux epaules etait plus eleve en cas d’extraction par ventouse (12,8 % versus 6,7 % ; p = 0,16), sans que cela n’engendre une augmentation du taux de complications fœtales. Aucune complication fœtale grave n’etait rapportee. Le taux d’echec etait plus eleve en cas d’extraction instrumentale par ventouse (11,4 % versus 4,4 % ; p = 0,04), sans augmentation du taux de cesariennes realisees pour echec d’extraction instrumentale (1,3 % versus 4,4 %). Discussion et conclusion Cette etude est la premiere a comparer les complications consecutives aux extractions par ventouse Kiwi ® par rapport a celles survenant avec les autres instruments. Bien que les resultats soient limites par le caractere retrospectif de l’etude et son faible effectif, l’utilisation de la ventouse Kiwi ® est associee a une tendance a la diminution du taux de complications maternelles, pour des taux de complications fœtales similaires a ceux retrouves en cas d’extraction par forceps et spatules. Il est donc legitime de promouvoir cet instrument et de former les jeunes praticiens a son usage. Notre etude a mis par ailleurs en evidence un des taux d’echec d’extraction instrumentale et de dystocie des epaules plus eleves. Des etudes complementaires seraient necessaires afin de mieux evaluer les situations a risque d’engendrer ces evenements afin de permettre un usage optimal de la ventouse Kiwi ® .

Superficial vascular malformations (MAV), so far called "superficial angioma", are uncommon and often unknown. The last classification, done by the "International Society for the Study of Vascular Anomalies", is essential to avoid diagnostic and therapeutic mistakes. Extramedullar localisations are rare. The coexistence of a pregnancy and a MAV states two problems: the medical and paraclinic supervision of the volume of the MAV and its risk of thrombosis with the choice of thrombosis prevention, and the mode of delivery and type of anaesthesia depending on its anatomical location. We revised the management of pregnant women with a MAV illustrating possible troubles to deal with. We reported the cases of two women having for the first one a pharyngolaryngeal MAV, the second a cutaneous MAV located on the leg and needing a multidisciplinary management with obstetricians, anaesthesists, hematologists, dermatologists, ENT, radiologists and pediatricians.

Lymph node staging in patients with locally advanced cervical cancer is the most important prognostic factor and also leads to adjuvant treatment choice. Because of the lymphadenectomy associated morbidity and delay in the beginning of adjuvant therapy, noninvasive approaches were developed during the last decennia. Recently, positron emission tomography employing a glucose analogue (FDG-PET) has been shown to be more sensitive and more specific than magnetic resonance imaging or than computed tomography usually used in diagnosis of pelvic and para-aortic lymph node metastases. Even if recent studies have reported promising results, surgical pelvic and para-aortic staging remains actually the most accurate procedure for evaluating lymph node metastases. This procedure should be accomplished by transperitoneal or extraperitoneal laparoscopy, with the benefits of minimal morbidity, shorter length of hospital stay and no significant increase of complications comparing to laparotomy approach. Laparoscopy also allows an early start of adjuvant treatment, this delay constituting an important prognostic factor for patients with locally advanced cancer. However, the survival benefit of lymph node dissection is still controversial and should be proved in randomised studies.

Early-stage cervical cancer (IA2 and IB1) treatment consists in surgery with a radical colpohysterectomy associated to a systematic pelvic lymphadenectomy more or less a paraaortic lymphadenectomy (Wertheim-Meigs surgery). Pelvic lymph node involvement is the main independent prognostic factor and justifies an adjuvant therapy. Sentinel lymph node (SLN) procedure allows a reliable evaluation of the lymph node status thanks to an accurate histologic analysis. This procedure is still not validated in practice, which means the bilateral pelvic lymphadenectomy is systematically done whatever the lymph node status is. Nevertheless the purpose of the SLN biopsy in cervical cancer does not consist in avoiding an unnecessary lymphadenectomy, which is not really associated with a major morbidity. Actually, a better initial stadification would allow to fit to the risk of recurrence not only the radicality of the surgery, but also the adjuvant therapy. The morbidity of a radical surgery could be limited for good prognosis patients and avoided for the benefit of a concomitant chemoradiotherapy.

Atypical hyperplasia represents 4% of all benign breast diseases. There are two different types: atypical ductal hyperplasia and atypical lobular hyperplasia. Aside columnar cell lesion. They represent an early stage of some forms of low grade carcinoma in situ and invasive carcinomas. Atypical hyperplasia is a benign lesion with intermediate carcinologic risk and the existence of a concomitant aggressive lesion should be suspected. When atypical lesion is found on a biopsy specimen, surgical excision is recommended especially in case of atypical ductal hyperplasia. A regular supervision is recommended.

Radioguided occult lesion localisation (ROLL) is a new technique which allows identification of non palpable breast lesion in breast cancer using, on the model of sentinel node procedure, injection of a radiotracer over the tumour lesion. With a gamma detection probe, it is then possible during surgery to identify in the same time the lesion and the sentinel lymph nodes. Compared with the wire-guided localisation (WGL), ROLL seems easier to achieve for radiologists, the excision procedure seems to be simpler with a good lesions resection in sano rate and a good cosmetic result.

In 10 to 15% of cases, breast cancer occurs in women under the age of 40. Thanks to the development of novel therapeutic approaches in the past few years, breast cancer prognosis is today far more acute than before and a pregnancy can be planned in these young women. They are expecting from their physician clear information about possibilities for pregnancy and specific risks after breast cancer. Several questions are raised in such situations: Does pregnancy modifies breast cancer prognosis? What is the influence of breast cancer for pregnancy? How do these young patients experience pregnancy and breast cancer? The goal of this paper, based upon literature review, was to clarify guidelines for the follow-up of young women experiencing pregnancy after breast cancer.

Sentinel lymph node biopsy is nowadays an accepted method of staging breast cancer patients. In case of an injection of radioactive colloid, preoperative lymphoscintigraphy is recommended to establish a lymphatic mapping and to predict the number of sentinel lymph nodes identified during surgery. Preoperative lymphoscintigraphy does not decrease the false-negative rate. However, positive preoperative lymphoscintigraphy significantly improves the identification rate of intraoperative sentinel nodes comparing with negative preoperative lymphoscintigraphy. Detecting extra-axillary sentinel lymph nodes, because of its minimal therapeutic consequences, does not appear to be an indication for preoperative lymphoscintigraphy. Given logistics and cost required, preoperative lymphoscintigraphy should be only performed for patients with a high risk of intraoperative failed localization. In case of negative preoperative lymphoscintigraphy, sentinel lymph node biopsy must be tried because sentinel nodes are still identified in the majority of these patients. Another possibility, with important cost and logistic, should consist in performing a later lymphoscintigraphy on the day after radioactive injection to ameliorate sentinel lymph nodes identification.

Resume La mifepristone, steroide antagoniste des recepteurs de la progesterone, peut agir par differents mecanismes sur la croissance des fibromes uterins. De nombreuses etudes sur des patientes volontaires symptomatiques ont ete effectuees depuis plus de dix ans. Une administration journaliere de 5 mg par jour de mifepristone permet d’obtenir une reduction significative du volume uterin et fibromateux et une amelioration de la qualite de vie des patientes. L’efficacite de ce traitement est comparable a celle des agonistes de la GnRH. Les effets secondaires observes sont des bouffees de chaleur dans 38 % des cas, une elevation des enzymes hepatiques dans 4 % des cas et la survenue d’une hyperplasie simple de l’endometre dans 28 % des cas. La survenue de bouffees de chaleur ou d’hyperplasies endometriales n’est pas observee a la dose de 5 mg par jour. L’utilisation de mifepristone pourrait peut-etre permettre d’eviter ainsi un certain nombre de prises en charge invasive. Cependant, les etudes realisees ne portent que sur une duree de prise de trois a 12 mois, et d’autres etudes sur une plus longue periode et portant sur un plus grand nombre de patientes sont necessaires avant de pouvoir proposer ce traitement au long cours.

Resume Objectifs Reduire la mortalite maternelle est une priorite de sante publique. L’une des principales causes de mortalite maternelle est l’hemorragie de la delivrance. Les actes de chirurgie entrent dans le cout global de prise en charge des hemorragies de la delivrance. Pour cette raison, il est important de connaitre leur cout propre pour proposer une recette pour un (ou des) futur(s) groupe homogene de malades (GHM) « hemorragie de la delivrance ». Materiel et methode L’evaluation relative aux beneficiaires a ete realisee a partir des donnees recueillies dans le service de gynecologie-obstetrique et de sterilisation d’un centre hospitalier universitaire realisant une prise en charge chirurgicale. L’analyse des couts de production a ete realisee a partir des couts reels. Les recettes ont ete elaborees sur la base des tarifs applicables en France en 2005 en prenant en compte les decisions de financement par les producteurs. Resultats Du 1er janvier 2004 au 31 decembre 2005, 262 prises en charge pour hemorragie de la delivrance ont ete realisees et 255 dossiers ont ete exploites. Les couts des actes chirurgicaux dans la prise en charge de l’hemorragie de la delivrance (n = 52) allaient de 875,06 € par hysterectomie (n = 5), 725,53 par tamponnement intra-abdominopelvien par des champs type Mikulicz ou ablation des champs de compression (n = 10), 601,55 par ligature (n = 3), 302,48 par revision sous valve (n = 26) a 275,04 € par revision uterine (n = 8). Le cout de la sterilisation des dispositifs medicaux representait, en fonction de l’acte realise, entre 7,5 % et 11,4 % des couts fixes. Discussion et conclusion Les couts de la prise en charge chirurgicale des hemorragies de la delivrance peuvent etre calcules pour donner des reperes au pilotage et au suivi de ces activites dans le cadre de la mise en œuvre de la T2A-EPRD et des poles d’activites. Ils peuvent participer a l’elaboration et au suivi d’un (ou des) futur(s) GHM « hemorragie de la delivrance ».

Since the advent of sentinel node biopsy, which made it possible to reduce the morbidity of axillary surgery, axillary lymph node dissection has been constituting the treatment of reference in certain cases of breast cancer. One of the most frequent complications in the immediate postoperative period is the lymphocele or seroma, the frequency of which is independent of the axillary technique of surgery. Following an analysis of the literature, some risk factors were isolated such as a high body mass index, the high volume of the first three days drainage and arterial hypertension. Some techniques seem to show a benefit in the reduction of the lymphocele: sentinel node biopsy, padding of the axilla and the axillary drainage. The majority of other techniques such as the use of fibrin sealant, hemolymphostatic sponges, various techniques of axillary dissection, external axillary compression, differed mobilization from the upper limb, axillary dissection by lipo-aspiration and endoscopic axillary dissection, have too contradictory results at the present time to be recommended in clinical practice. No consensus is clearly established to decrease the incidence and the volume of the seroma after axillary dissection in breast cancer. Today, two techniques can be nevertheless distinguished: sentinel node biopsy and padding of the axilla.

Resume Objectif Le cancer du sein bilateral synchrone (CSBS) n’est pas une entite rare, et les femmes deja atteintes d’un cancer unilateral ont un risque supplementaire de cancer controlateral. L’objectif de cette etude a ete d’evaluer les caracteristiques et le traitement des cancers du sein bilateraux synchrones (CSBS). Patientes et methodes Entre juillet 1992 et mai 2006, 62 patientes ont ete prises en charge pour un CSBS. Les tumeurs ont ete separees en tumeurs droite et gauche et la population divisee en deux periodes d’etude. Les donnees epidemiologiques, les circonstances diagnostiques, les traitements et les caracteristiques histologiques tumorales ont ete analyses et compares entre les differents groupes d’etude. Resultats L’incidence globale des CSBS etait de 2,6 %. Les patientes presentant un CSBS avaient un antecedent familial de cancer du sein dans 23,7 % des cas. Le tableau le plus frequent associait une tumeur palpable a une lesion controlaterale infraclinique (43,5 %). L’IRM a permis de diagnostiquer sept tumeurs. Parmi les patientes, 38,7 % ont eu une mastectomie bilaterale et 33,9 % ont beneficie de la technique du ganglion sentinelle. La proportion de carcinomes lobulaires invasifs etait de 17,7 %, identique a celle de tumeurs multifocales. Les tumeurs droite et gauche etaient du meme type histologique dans 78,3 % des cas et l’expression des recepteurs aux œstrogenes etait identique dans 91,4 % des cas. Discussion et conclusion Les principaux facteurs de risque de CSBS sont la notion d’une histoire familiale de cancer du sein, le type histologique lobulaire invasif et le caractere multifocal de la premiere tumeur. Une prise en charge chirurgicale conservatrice est possible ainsi que l’utilisation de la technique du ganglion sentinelle. Les CSBS ont des similitudes histologiques, probablement dues a des facteurs environnementaux.

The sentinel lymph node procedure has become the standard in the surgical management of localised breast cancer. However, it is submitted to the uncertainties of intraoperative examination. Indeed, intraoperative examination has three major disadvantages: the type of histological method (frozen section versus imprint cytology), the size of sentinel node metastasis (macro- versus micrometastases) and the time requested for this technique. All of these limits are responsible for secondary re-interventions to complete axillary lymph node dissection. Few medical teams have described a new surgical strategy to avoid these limits. They proposed the detection of the sentinel lymph node under local anaesthesia and to wait for the definitive histological analysis before carrying out lumpectomy and axillary lymphadenectomy if necessary under general anaesthesia. We realized a review of the literature on this new procedure to evaluate its feasibility and to assess the technical aspects.

Axillary lymph node dissection (ALND) is recommended for patients with breast cancer metastasis to a sentinel lymph node (SLN). However in 40-70% of cases, the SLN may be the only area of metastasis in the dissected axillary contents. In patients with a positive SLN, independently predictive factors for non-SLN metastasis include size of the primary tumor, the size of the SLN metastases, extracapsular extension, and the proportion of positive SLN's among all identified SLNs. Some authors have developed scores and nomograms to estimate a patient's risk for non-SLN metastases. These scores and nomograms should be applied prospectively to a large numper of SLN positive patients who thereafter undergo completion ALND. It is necessary to verify the predictive validity of these scores before we recommend the abandonment of ALND in patients with a very low likelihood of non-SLN metastasis. In this article we review the various predictive factors of non-SLN involvement and the scores or nomograms which have been developed to predict the likelihood of a positive ALND after a positive SLN biopsy.

Parvovirus B19 infection during pregnancy is at risk of adverse fetal outcome. The risk is increased if maternal infection occurs during the first two trimesters, but may also happen during the third trimester. Adverse first and third trimester fetal outcome were recently highlighted by polymerase chain reaction (PCR) viral DNA detection. Parvovirus does not seem to be a significant teratogen. Infection during pregnancy can cause severe fetal anaemia and nonimmune hydrops fetalis. Cardiac tropism of the virus can cause myocarditis and aggravate the cardiac failure. Follow up of in utero anaemia is based upon the middle cerebral artery peak systolic flow velocity evaluation and treatment is based upon cordocentesis transfusion.

Metabolic acidemia may cause cerebral palsy or perinatal death. Its detection is the major goal of perpartum fetal evaluation. Sensitivity of continuous fetal heart rate analysis is excellent, but the lack of specificity of this test can lead to inadequate intervention during labour. Fetal scalp pH is directly reliable to fetal acid-base status. In every situation where fetal heart rate displays ominous pattern, a potential acidemia can be detected with fetal scalp pH analysis. Intervention is recommended in the next 30min when fetal scalp pH is bellow 7.20. Complete analysis of fetal acid-base status parameters, including base excess and lactatemia allows a more precise detection of metabolic acidemia. Described since 1962, the place of fetal scalp pH analysis is still central in our daily practice.

In cervical cancer, lymph node status is a major prognostic factor and a decision criterion for adjuvant therapy warranting the lymphadenectomy. The sentinel node procedure, which has emerged to reduce morbidity of extensive lymphadenectomy, remains a major step in the surgical management of solid cancers. Sentinel node procedure has become a standard technique for the determination of the nodal stage of the disease in patients with melanoma, vulvar cancer and recently in breast cancer. In cervical cancer, the sentinel node biopsy is still at the stage of feasibility. In this article, we review the technical aspects, results and clinical implications of sentinel node procedure in cervical cancer.

Indications of GnRH analogues before and/or after surgery for endometriosis remain controversial. Although some studies have underlined a decrease in rAFS scores using GnRH analogues pre-operatively, data are insufficient to recommend their systematic use in routine. In the same way, despite an increase in symptom free period subsequent to the use of GnRH analogues post-operatively, no effect of this therapeutic on recurrence rate and fertility outcome has been proved. In addition to a meta-analysis on GnRH analogues in endometriotic women, further studies, especially in women with large endometriomas and with deep pelvic endometriosis, are required to clarify the indications of GnRH analogues associated with surgical management.

Resume Dans les cancers de l’uterus, le statut ganglionnaire constitue un facteur pronostique important, ainsi qu’un critere decisionnel majeur de traitement adjuvant, rendant l’exploration ganglionnaire indispensable. La detection du ganglion sentinelle, qui s’est developpee dans le dessein de reduire la morbidite de la chirurgie, represente une avancee majeure dans la prise en charge chirurgicale de plusieurs cancers. Cette technique a rapidement ete adoptee dans le melanome, le cancer de la vulve et recemment dans le cancer du sein. Dans les cancers du col et de l’endometre, cette procedure est au stade de faisabilite. Dans cet article, nous evoquons les aspects techniques, les resultats ainsi que les applications potentielles de la technique de la detection du ganglion sentinelle dans les cancers du col de l’uterus et de l’endometre.

In cancer research, regional lymph node status is a major prognostic factor and a decision criterion for adjuvant therapy warranting the lymphadenectomy. The sentinel node procedure, which has emerged to reduce morbidity of extensive lymphadenectomy, remains a major step in the surgical management of various cancers. Sentinel node procedure has become a standard technique for the determination of the nodal stage of the disease in patients with melanoma, vulvar cancer and recently in breast cancer. In cervical and endometrial cancers, the sentinel node biopsy is still at the stage of feasibility. In this article, we review the technical aspects, results and clinical implications of sentinel node procedure in cervical and endometrial cancers.

Sentinel lymph node biopsy for breast cancer has been introduced in the mid-1990s and it has now been performed on thousands of patients. Although this procedure has not been validated by randomised clinical trials, it has been rapidly adopted around the world by surgical specialists in clinical practice as a diagnostic procedure instead of the axillary lymph node dissection. The critical issue in sentinel lymph node biopsy is the false negative results which could expose the patients to axillary recurrence and lead to understaging and incorrect adjuvant therapy decisions. The current problem is to perfect the procedure for an optimal use in routine reducing this risk of false negative results. This false negative rate declines sharply when the technique is performed in selected patients by experienced surgeons using a combined detection. In this article, we review the technical aspects and results of the sentinel lymph node biopsy in breast cancer and discuss the recommendations for the optimal clinical practice.

Introduction For the excision of nonpalpable breast lesions, the surgeon needs a landmark previously placed under radiological or ultrasound imaging control. The current technique consists in implanting a metal wire from the lesion to the skin, which presents some constraints in terms of patient comfort, surgery precision (potential wire migration) and medical organization. Here is presented the implementation of breast lesion localization using an 125I radioactive seed as part of a mononoclinical trial comparing the wire-guided and radioguided techniques. Today, a feedback over 18 patients enables a first report on this technique. Methods In order to insure the feasibility of the iodine seed (IsoSeed® - Eckert & Ziegler) technique, the radiopaque and echogenic seed’s features were checked. In the surgery room, the iodine seed (A Results The seed is visible under X-Ray and ultrasound imaging. Thus this localization technique is possible, as well as the control of the seed presence into the lesion using Faxitron imaging (X-Ray). The 11 mm diameter probe was approved by the surgeons. With a 1.5 cm focalization (FWHM of the radial sensitivity curve), it offers the best compromise sensitivity/focalization. In light of the clinical activities, the scattered radiation of 99mTc does not trouble the 125I seed detection. For a seed implanted at 1, 2 and 3 cm depth, the breast skin dose was respectively evaluated at 2.2, 0.5 and 0.2 mGy/MBq/day. The highest activity and implantation duration being 10 MBq and 10 days, there is no contraindication to this technique due to radioprotection. The simulation using the piece of meat led to validate every step of the protocol with the different operators and thus resolve every major difficulty in relation to this technique. Conclusions The 18 iodine seed localizations (activity: 4.4 ± 1.5 MBq (1 σ ) , presence duration in the breast: 4.6 ± 3 days (1 σ ) ) were successful and enabled to optimize the established protocol. They confirm that this technique brings the solution to the constraints linked to the wire-guided localization: the seed positioning and the surgery gesture are made easier, the patient comfort is unquestionably improved and the medical organization flows better. Today, no seed migration has been observed, which may also promise a gain in precision.