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Resume Objectif Etablir les differentes caracteristiques anatomocliniques des cancers ovariens chez les patientes aux antecedents d’hysterectomie pour pathologie benigne. Patientes et methodes Il s’agit d’une etude retrospective, monocentrique, descriptive, comparative realisee au centre Jean-Perrin chez des patientes atteintes d’un cancer de l’ovaire entre 2005 et 2014 et ayant un antecedent d’hysterectomie pour pathologie benigne. Chaque patiente a beneficie d’un appariement a des patientes atteintes d’un cancer de l’ovaire et n’ayant pas subi d’hysterectomie au prealable. Les deux populations ont ete appariees a 1 : 5, sur l’âge au diagnostic et le stade FIGO de la maladie. Resultats Sur la periode etudiee, 249 patientes ont ete operees de novo pour neoplasie ovarienne, 43 patientes presentaient un antecedent d’hysterectomie (groupe 1) et 206 patientes restantes etaient considerees comme temoins (groupe 2). Il n’existait pas de difference en termes de survie globale et de survie sans recidive entre les deux sous-populations de patientes (respectivement p = 0,59 et p = 0,38). Sur les elements scannographiques, le risque radiologique d’envahissement ganglionnaire etait superieur a 2,6 dans le groupe des patientes hysterectomisees (p = 0,00038). Les scores PCI des deux sous-groupes de populations etaient comparables, on retrouvait une moyenne de 13,65 pour le groupe 1 versus 12,31 pour le groupe 2 (p = 0,28). Le taux de realisation de resection rectosigmoidienne etait plus eleve dans le groupe 1 : 48,6 % versus 32,9 % dans le groupe 2 meme s’il n’existait pas de difference significative (p = 0,07). Cent trente-trois patientes ont beneficie d’un curage lombo-aortique, celui ci etait envahi pour 83 % des patientes du groupe des hysterectomisees et pour 51 % des patientes du groupe temoin (p = 0,0053). Conclusion Cette etude met en evidence une atteinte ganglionnaire lombo-aortique plus importante en cas d’antecedent d’hysterectomie. Ces donnees meritent de proposer une etude prospective comparative et multicentrique.

Le traitement conservateur est actuellement la reference dans la prise en charge des cancers du sein de stades I et II. L’obtention de marges saines est un facteur primordial pour la diminution du taux de recidives locales. Elle ne fait l’objet d’aucun consensus tant pour la technique d’evaluation des berges chirurgicales que pour la valeur seuil limite d’une marge d’exerese de securite. Diverses approches ont ete evaluees dans la litterature, depuis la prise en charge macroscopique de la piece a sa reception par le pathologiste a l’emploi de methodes cytologiques et histologiques d’evaluation des berges. De telles pratiques sont evidemment a replacer dans un contexte radioclinique et doivent faire l’objet d’une collaboration etroite entre les differents specialistes. Les perspectives sont une amelioration de l’evaluation des limites et/ou des marges tumorales a l’aide de techniques de medecine nucleaire, et/ou de biologie moleculaire afin de diminuer le nombre de reprises chirurgicales.

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.

Resume But de l’etude evaluer la morbidite de quatre techniques de reconstruction mammaire immediate (RMI) apres chimiotherapie et radiotherapie externe (RTE) pre-operatoire. Patients et methodes 101 patientes ont eu une RMI apres chimiotherapie et RTE pre-operatoire pour une tumeur invasive du sein. 38 patientes ont eu une RMI par lambeau musculocutane de grand droit (TRAM), 32 par lambeau de grand dorsal avec prothese (GDP), 15 par lambeau de grand dorsal autologue (GDA), et 26 par implant prothetique (P). Resultat les taux de complications de la RMI par TRAM, GDP, GDA et P etaient respectivement de 50 %, 37,5 %, 85 %, 62 %. Les reprises chirurgicales etaient respectivement de 29 %, 15 %, 6 %, 56 %. Il existait un taux de complications significativement plus important (p = 0,013) pour les RMI par GDA (Risque Relatif -RR = 1,73 ; intervalle de confiance a 95 % – IC 95 % – = 1,12-2,69) et un taux significativement plus important (p = 0,00087) de reprises chirurgicales pour les RMI par implant prothetique (RR = 1,99 ; IC 95 % = 1,11-3,59). Conclusion La RMI par lambeau musculocutane est a privilegier par rapport aux RMI prothetiques simples apres RTE et chimiotherapie pre-operatoire.

Resume Objectifs Evaluer l'interet de la recherche du ganglion axillaire sentinelle dans les carcinomes canalaires in situ du sein avec micro-invasion. Patientes et methodes Entre janvier 2001 et janvier 2006, l'adenectomie sentinelle a ete realisee par technique isotopique et/ou colorimetrique pour 41 carcinomes canalaires in situ avec micro-invasion prouvee sur biopsie percutanee initiale ou sur piece d'exerese operatoire. Le curage axillaire complet a ete accompli dans les dix premiers cas de facon systematique, puis chaque fois que le ganglion sentinelle etait envahi, qu'il s'agisse d'une macrometastase ou d'une micrometastase. Resultats Le taux de detection du ganglion sentinelle etait de 98 % (40/41), l'echec survenant apres biopsie–exerese chirurgicale. Le nombre moyen de ganglions sentinelles preleves etait de deux (extremes 1–5). Le taux d'envahissement du ganglion sentinelle etait de 10 % (4/40) : une macrometastase pN1, deux micrometastases visibles en coloration standard (HES, hematoxyline–eosine–safran) pN1 (mi), une micrometastase detectee en immunohistochimie pN0 (mi). Discussion et conclusion La recherche du ganglion sentinelle ne devrait pas se developper pour l'ensemble des carcinomes canalaires in situ mais pour les plus pejoratifs d'entre eux, selectionnes sur des criteres cliniques, radiologiques et histologiques. Grâce aux prelevements percutanes micro-/macrobiopsiques initiaux, la planification du ganglion sentinelle est permise pour les carcinomes canalaires in situ micro-invasifs prouves ou probables des le debut de la prise en charge chirurgicale avant que les remaniements cicatriciels — et a fortiori la mammectomie eventuelle — ne viennent compromettre techniquement son application.

Resume Objectif Savoir identifier le muscle pectoro-axillaire (ou arche de Langer) et connaitre les artifices chirurgicaux de la lymphadenectomie axillaire sentinelle. Patientes et methodes Dans une serie prospective clinique sur cinq ans, nous avons identifie la presence du muscle pectoro-axillaire lors de chaque lymphadenectomie sentinelle. Resultats Nous retrouvons une prevalence de 1,7 %, avec une legere predominance pour l'unilateralite, et une localisation du ganglion sentinelle au contact ou en arriere du muscle. Les difficultes de dissection liees a l'arche de Langer sont retrouvees dans 40 %. Discussion et conclusion Apres un rappel embryologique et anatomique, nous decrivons les difficultes possibles en cas de meconnaissance de ce muscle et les techniques chirurgicales qui peuvent faciliter les lymphadenectomie axillaires sentinelles. Il est indispensable de connaitre et de penser a l'existence de ce muscle lors de toute recherche de ganglion sentinelle tant la dissection axillaire peut autrement s'averer compliquee.

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 35 - N° 8 - p. 829-833

La frequence relative des cancers de l’ovaire aux stades avances explique leur mauvais pronostic. Celui-ci ne peut etre ameliore que par une bonne sensibilite aux chimiotherapies actuelles (Carboplatine + Paclitaxel) et une reduction chirurgicale macroscopiquement complete du volume tumoral. L’extension tumorale intra-abdominale etant tres heterogene, la complexite des interventions pour parvenir a une exerese complete est tres variable. On distingue des procedures standards, radicales et supraradicales, ces deux derniers niveaux comportant une exerese digestive qui se revele necessaire une fois sur deux. Les chances de parvenir a une exerese complete dependent de l’experience du chirurgien et de la resecabilite tumorale qui peut etre appreciee cliniquement et grâce au scanner. Actuellement, les meilleures chances pourraient etre donnees aux malades en les confiant a des equipes experimentees aptes a selectionner celles qui ont des tumeurs resecables et qui doivent etre operees d’emblee et celles dont la tumeur a peu de chance d’etre resequee et qui pourraient beneficier d’une strategie de chimiotherapie premiere avec chirurgie d’intervalle apres trois ou quatre cures.

Resume Objectif. – L'emergence du diagnostic preoperatoire grâce a de nouvelles methodes de micro- et macrobiopsies et l'apparition de la technique du ganglion sentinelle ont totalement modifie la prise en charge chirurgicale des patientes presentant une tumeur mammaire. L'objectif de cette etude est de determiner si l'examen extemporane reste un outil indispensable dans la prise en charge diagnostique et therapeutique du cancer du sein. Patientes et methodes. – Etude retrospective comparant l'evolution qualitative des examens extemporanes en pathologie mammaire au centre Jean-Perrin avant l'utilisation d'un appareil dedie aux biopsies stereotaxiques percutanees (Mammotome®) et apres la phase d'apprentissage de la technique du ganglion sentinelle et son application en routine. Resultats. – Nous avons observe une redistribution de l'activite anatomocytopathologique avec diminution des examens histologiques extemporanes sur tumeur mammaire (307 versus 168 avec p Discussion et conclusion. – L'interet du diagnostic histologique pretherapeutique et l'absence de consensus sur la pratique de l'analyse anatomocytopathologique peroperatoire du ganglion sentinelle tendent a reduire les indications de l'examen extemporane dans le cancer du sein.

Resume Objectifs. – Recenser et decrire les cas particuliers de cancers de l'endometre developpes sur des polypes endocavitaires pendant une hormonotherapie par tamoxifene pour cancer du sein. Patientes et methodes. – Dans l'inventaire chirurgical 1990–2002 des lesions uterines benignes ou malignes ayant fait l'objet d'une hysteroscopie avec curetage biopsique et/ou d'une hysterectomie, 108 polypes endometriaux uniques ou multiples ont ete formellement diagnostiques et histologiquement analyses. Resultats. – Une degenerescence neoplasique du polype a ete mise en evidence sur cinq pieces operatoires, soit un taux de 4,6 % c'est-a-dire 5/108 : quatre cas de degenerescence adenocarcinomateuse, un cas de degenerescence sarcomateuse. Discussion et conclusion. – L'existence de polypes endocavitaires — symptomatiques ou non — ne semble pas compatible avec l'utilisation prolongee du tamoxifene compte tenu des effets agonistes potentiels et de ses consequences hyperplasiques et carcinogeniques endometriales connues. Les risques de cancerisation des polypes endometriaux difficilement quantifiables dans ce climat iatrogenique sont estimes entre 2,5 et 10 % dans la litterature.

Resume Objectif Preciser le role du curage ganglionnaire axillaire dans les carcinomes canalaires in situ micro-invasifs (CCIS-MI) du sein a partir d’une serie de 107 cas consecutifs. Methodes Travail anatomoclinique retrospectif monocentrique avec application des recommandations europeennes en adoptant comme definition pathologique la presence de foyer(s) de micro-invasion n’excedant pas 1 mm. Le curage axillaire etait systematiquement complet ; il a ete precede chez 10 malades par la recherche du ganglion sentinelle par methode isotopique. Resultats L’envahissement ganglionnaire a ete mis en evidence dans 8 cas sur l’ensemble de l’effectif (7,5 %) ; tous les cas, sauf un, comportaient des caracteristiques histologiques pejoratives communes : sous-type architectural comedo, haut grade nucleaire, taille lesionnelle > 3 cm. Le taux d’envahissement ganglionnaire atteignait 18,5 % dans le sous-groupe des comedocarcinomes micro-invasifs de haut grade mesurant plus de 3 cm. Conclusion Contrairement aux CCIS purs, les CCIS-MI necessitent une exploration chirurgicale de l’aisselle dont les modalites les mieux appropriees sont aujourd’hui discutees : curage ganglionnaire axillaire classique ou recherche du ganglion sentinelle, ce procede d’adenectomie selective n’etant pas encore une technique consensuellement validee.

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

We report four cases of mixed mullerian tumors of the endometrium arising in postmenopausal women taking tamoxifen for breast carcinoma. Various histopathologic features were encountered: one mullerian adenosarcoma and three malignant mixed mullerian 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 mullerian tumors. There is no consensus regarding internal surveillance of women receiving tamoxifen. The usefulness of pelvic sonography has not been demonstrated.

Resume But de l’etude. – Evaluer dans notre experience la morbidite du lambeau musculocutane du droit ou trans rectus abdominis musculocutaneous flap (TF), rechercher les facteurs de risques de complications et determiner l’interet d’une autonomisation prealable du lambeau. Patients et methodes. – Cent vingt-cinq patientes consecutives ont eu une reconstruction par TF. Parmi elles, 38 (30,4 %) presentaient une recidive locale apres traitement conservateur et 62 (49,6 %) ont ete incluses dans un protocole associant chimiotherapie premiere, radiotherapie puis mastectomie de cloture avec reconstruction mammaire immediate (RMI), 31 patientes etaient obeses (24,8 %), 14 etaient fumeuses (11,2 %), 118 (94,4 %) avaient eu une irradiation thoracique anterieure, 97 (77,6 %) ont eu une autonomisation prealable du lambeau par ligature du pedicule epigastrique inferieur, 115 (92 %) ont eu une RMI, 99 lambeaux unipedicules et 26 lambeaux bipedicules ont ete realises. Resultats. – Les complications immediates ont ete : 21 necroses du lambeau (16,8 %) dont une necrose totale (0,8 %), 6 hematomes (4,8 %). Les complications secondaires ont ete : 14 cytosteatonecroses du sein reconstruit (11,2 %), 9 eventrations parietales (7,2 %), 6 hernies abdominales (4,8 %). Le seul facteur de risque ischemique retrouve a ete l’obesite ( p = 0,036). La refection parietale par plaque est le seul facteur ayant diminue le risque d’eventration ou de hernie ( p = 0,013). L’autonomisation du lambeau n’a pas diminue significativement le taux de complication ischemique ( p = 0,92). Conclusion. – Dans une equipe entrainee aux techniques de reconstruction mammaire, le TF peut etre realise avec un taux de complication acceptable chez des patientes selectionnees. La place et la technique d’autonomisation du lambeau, dans notre experience, doivent etre reconsiderees.

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.

Resume Introduction. – Le tamoxifene est un anti-estrogene triphenylethylenique de synthese utilise dans le traitement du cancer du sein. Les effets indesirables de ce medicament derive du diethylstilboestrol proviennent de son action agoniste partielle des estrogenes : ces effets « paradoxaux » concernent essentiellement l’uterus avec une augmentation du risque de cancer de l’endometre. Exegese. – Les auteurs rapportent deux cas cliniques de sarcome uterin survenu chez des femmes menopausees prenant du tamoxifene, a la dose conventionnelle de 20 mg/j depuis 38 et 42 mois, comme traitement hormonal adjuvant d’un cancer du sein. Il sˈagissait d’un leiomyosarcome et d’un sarcome stromal, tous les deux asymptomatiques decouverts lors d’un examen echographique transvaginale systematique. Conclusion. – A cote des nombreux adenocarcinomes endometriaux developpes sous tamoxifene, generalement bien differencies et reveles par des metrorragies, des tumeurs plus rares et plus agressives ont ete ponctuellement observees sans distinction d’un lien etiopathogenique particulier. Les modalites de surveillance du tamoxifene ne font pas encore l’objet d’un consensus. Dans les deux cas presentes ici, le sarcome uterin a ete detecte par echographie en l’absence de metrorragies post-menopausiques. Nous restons partisans d’un examen gynecologique avec echographie endovaginale une fois par an chez les patientes prenant du tamoxifene pour cancer du sein.

Resume Introduction. – Le syndrome de Stewart-Treves a ete defini par les auteurs eponymes comme un lymphangiosarcome cutane survenant sur un lymphœdeme chronique du bras apres mastectomie suivie ou non dˈirradiation. Exegese. – Le cas rapporte correspondait a un angiosarcome cutane, d’expression clinique nodulaire violacee, developpe sur un lymphœdeme du membre superieur neuf ans apres une mammectomie radicale avec curage ganglionnaire axillaire pour cancer du sein completee dˈune radiotherapie externe au cobalt. Les tests immunohistochimiques ont permis d’eliminer l’hypothese d’une metastase cutaneobrachiale d’origine mammaire et d’affirmer la nature vasculaire sarcomateuse de la tumeur. Conclusion. – Les cas de syndrome de Stewart-Treves devraient se rarefier avec le declin des mastectomies (supra-)radicales, les methodes de recherche du ganglion axillaire sentinelle et la systematisation des mesures de prophylaxie du lymphœdeme brachial sequellaire.

Resume Etude retrospective (1985–1998) portant sur les caracteristiques operatoires et anatomopathologiques de 155 cancers infracliniques du sein reveles par une opacite stellaire. Materiels et methodes – Les mammographies provenaient du depistage individuel ou organise. L’âge moyen etait de 58,5 ans (44–78), 129 patientes etaient menopausees (83 %). Le reperage preoperatoire etait stereotaxique dans 57 cas (36,5 %), echographique dans 98 cas (63,5 %). Le diametre lesionnel etait 97 fois inferieur ou egal a 10 mm dont 15 inferieur ou egal a 5mm, moyenne : 11 mm (extremes : 4–25). Le curage axillaire a ete realise 147 fois immediatement (95 %), huit fois secondairement (5 %). Resultats – Les cancers infracliniques du sein donnant une image stellaire correspondaient a des cancers infiltrants : canalaires (CCI) dans 130 cas (84 %), lobulaires (CLI) dans 25 cas (16 %). Aucun cancer canalaire in situ (CCIS) n’a ete revele ainsi. Le grade SBR a ete formule pour les CCI : 95 grade I (73 %), 31 grade II (24 %) et quatre grade III (3 %). Les recepteurs hormonaux ont ete doses sur 145 pieces : recepteurs œstrogeniques et progesteroniques etaient tous les deux positifs dans 125 cas (86 %). Un envahissement ganglionnaire (N+) a ete retrouve dans dix cas (6 %), tous CCI superieurs ou egaux a 5 mm. Cent cinquante traitements conservateurs (97 %) ont ete effectues. Commentaires – Les cancers stellaires sont generalement infiltrants de type canalaire mais aussi lobulaire. Ils se distinguent donc des cancers reveles par des microcalcifications, essentiellement de type canalaire dans leurs formes infiltrantes mais aussi in situ (CCIS). Dans cette serie, les cancers stellaires reunissaient des criteres histologiques et biologiques favorables : differenciation et hormonodependance frequente (trois fois sur quatre), N+ exceptionnel.

Resume But de l'etude : Cette etude avait pour but de rapporter une serie de 80 patients traites par abord unilateral pour une hyperparathyroidie (HPT I) sporadique. Patients et methode : Entre avril 1992 et novembre 1998, 80 patients (65 femmes et 15 hommes, âge moyen : 63,5 ans) ayant une hypertrophie parathyroidienne unique localisee par echographie, ont ete operes par une courte cervicotomie laterale, sous anesthesie generale dans 72 cas, locale dans huit cas. La glande enlevee etait confiee a l'examen histologique extemporane et un dosage peroperatoire de la parathormone intacte (PTHi) etait effectue par une methode rapide. Resultats : La duree moyenne de l'intervention a ete de 25 minutes. Il n'y a eu ni mortalite, ni morbidite postoperatoires. La duree moyenne de sejour a l'hopital a ete de deux jours. Il s'agissait d'un adenome parathyroidien dans 75 cas, d'une hyperplasie dans cinq cas. Le dosage de la PTHi a montre une diminution satisfaisante apres l'exerese. La calcemie postoperatoire etait normale chez 78 patients (97,5 %). Parmi les 76 patients survivant avec un recul moyen de 31 mois, il y avait seulement une suspicion d'hyperparathyroidie persistante dans deux cas. Conclusion : Le traitement de l'HPT I sporadique peut etre effectue par un abord unilateral mini-invasif si on selectionne les patients ayant un adenome unique et si on realise un dosage peroperatoire de la PTHi.

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.

Resume Le leiomyome uterin est une tumeur benigne frequente chez la femme en periode d'activite genitale. Parmi les complications possibles, la polyglobulie est rare et souvent meconnue. Nous rapportons un cas clinique tres demonstratif de l'association fibrome et polyglobulie chez une femme de 52 ans dont le motif de consultation initiale etait des metrorragies. La difficulte de la demarche diagnostique et le traitement sont detailles. Les differentes hypotheses physiopathologiques sont discutees afin d'eclaircir nos connaissances sur ce syndrome polyglobulie et fibrome, et d'optimiser la prise en charge therapeutique.

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.

126 patients with non-inflammatory operable breast cancer, who otherwise would have undergone modified radical mastectomy (MRM), were treated by induction chemotherapy. Before treatment, every patient had a local and general assessment, and pathological or cytological evidence of malignancy. Patients received, every 3 weeks, the same treatment with doxorubicin, vincristine, cyclophosphamide, 5-fluorouracil (AVCF); methotrexate was added in 80 cases (AVCFM). Tumour shrinkage greater than 50% was documented in 105 (83%) of the 126 women. A higher objective response rate was obtained in aneuploid or high S phase tumours, especially in the patients treated with methotrexate. After chemotherapy, 41 patients were then treated by radiotherapy alone after complete or sub-complete response; 64 had a residual tumour that could be treated by conservative surgery and radiotherapy. Only 19 had MRM and radiotherapy. Histopathological complete remission was documented in 1 case; isolated residual tumour cells were found in 5 patients. Thus primary chemotherapy enhanced the possibility of breast conservation in up to 83% of the cases in a series in which most would have been otherwise subjected to a MRM because of tumour size.

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.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.Mean dysplasia score was significantly higher in the genetic risk and stimulated ovary groups than in controls (9.55 versus 3.62, p0.0001; 7.51 versus 3.62, p0.0002, 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.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.

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.

Tamoxifen, an anti-estrogen widely used for breast cancer treatment, has variable agonistic effects on the uterus (mostly concerning endometrium but also myometrium). 14 cases of growing uterine fibroleiomyomas during tamoxifen treatment which required hysterectomy are described. No myometrial malignancy was observed.

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.

To investigate the role of sentinel lymph node biopsy for microinvasive ductal carcinoma in situ of the breast.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).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).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.

Identify the axillopectoral muscle (usually called Langer's axillary arch) and know the main surgical techniques of axillary sentinel node biopsies.We present the results of our five-year clinical prospective study: the presence of this anomaly is diagnosed peroperatively during a sentinel node biopsy.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%.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.

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.

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.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.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.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.

To review and describe the anatomoclinical cases of the endometrial cancers arising on polyps during a hormonotherapy by tamoxifen for breast cancer.In the surgical inventory 1990-2002 of the benign or malignant uterine lesions investigated by hysteroscopy with dilatationcurettage (DC) and/or hysterectomy, 108 single or multiple endometrial polyps were encountered and histologically analyzed.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.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.

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.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.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 lesion3 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.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.

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.

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.

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.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.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.

Only a few papers have been published concerning the incidence and outcome of patients with a pathological complete response after cytotoxic treatment in breast cancer. The purpose of this retrospective study was to assess the outcome of patients found to have a pathological complete response in both the breast and axillary lymph nodes after neoadjuvant chemotherapy for operable breast cancer. Our goal was also to determine whether the residual pathological size of the tumour in breast could be correlated with pathological node status. Between 1982 and 2000, 451 consecutive patients were registered into five prospective phase II trials. After six cycles, 396 patients underwent surgery with axillary dissection for 277 patients (69.9%). Pathological response was evaluated according to the Chevallier's classification. At a median follow-up of 8 years, survival was analysed as a function of pathological response. A pathological complete response rate was obtained in 60 patients (15.2%) after induction chemotherapy. Breast tumour persistence was significantly related to positive axillary nodes (P=5.10−6). At 15 years, overall survival and disease-free survival rates were significantly higher in the group who had a pathological complete response than in the group who had less than a pathological complete response (P=0.047 and P=0.024, respectively). In the absence of pathological complete response and furthermore when there is a notable remaining pathological disease, axillary dissection is still important to determine a major prognostic factor and subsequently, a second non cross resistant adjuvant regimen or high dose chemotherapy could lead to a survival benefit. British Journal of Cancer (2002) 86, 1041–1046. DOI: 10.1038/sj/bjc/6600210 www.bjcancer.com © 2002 Cancer Research UK

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.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.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).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.

Leiomyomatosis is a benign smooth muscle tumor which can provoke serious complications in case of intracaval or intracardiac extension.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.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.

To assess the characteristic features of ovarian carcinoma mucocellular secondary to breast cancer.A retrospective pathology evaluation of ovariectomy specimens was conducted to compare the histological types with the original pathology diagnosis of breast cancer.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.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 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.

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 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.