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The aim of this study was to analyze the skeletal, dental and airway changes with endoscopically assisted surgical expansion (EASE) to widen the nasomaxillary complex for the treatment of sleep apnea in adults.One hundred and five consecutive patients underwent EASE. Cone beam computed tomography (CBCT) was conducted preoperatively and within four weeks after the completion of the expansion process. Computational fluid dynamic (CFD) analysis was performed on 20 randomly selected patients to assess airway flow changes.One hundred patients (67 males) with the mean age of 35.0±13.5 years (17-64 years) had completed pre- and post-expansion imaging. Ninety-six patients (96%) had successful expansion defined as separation of the midpalatal suture at least 1 mm from anterior nasal spine (ANS) to posterior nasal spine (PNS). The nasal cavity expansion was 3.12±1.11 mm at ANS, 3.64±1.06 mm at first molar and 2.39±1.15 mm at PNS. The zygoma expansion was 2.17±1.11 mm. The ratio of dental expansion to skeletal expansion was 1.23:1 (3.83 mm:3.12 mm) at canine and 1.31:1 (4.77 mm:3.64 mm) at first molar. CFD airway simulation showed a dynamic change following expansion throughout the airway. The mean negative pressure improved in the nasal airway (from -395.5±721.0 to -32.7±19.2 Pa), nasopharyngal airway (from -394.2±719.4 to -33.6±18.5 Pa), oropharyngeal airway (from -405.9±710.8 to -39.4±19.3 Pa) and hypopharyngeal airway (from -422.6±704.9 to -55.1±33.7 Pa). The mean airflow velocity within the nasal airway decreased from 18.8±15.9 to 7.6±2.0 m/s and the oropharyngeal airway decreased from 4.2±2.9 to 3.2±1.2 m/s. The velocity did not change significantly in the nasopharyngeal and hypopharyngeal regions.EASE results in expansion of the midpalatal suture from the ANS to PNS with a nearly pure skeletal movement of minimal dental effect. The expansion of the nasomaxillary complex resulted in the widening of the nasal sidewall throughout the nasal cavity. The improved air flow dynamics was demonstrated by CFD simulation.L’objectif de cette étude était d’analyser les modifications obtenues au niveau du squelette, des dents et des voies respiratoires lors d’une expansion nasomaxillaire chirurgicale assistée par endoscopie (EASE), visant à élargir le complexe nasomaxillaire pour le traitement de l’apnée du sommeil chez des adultes.Cent cinq patients consécutifs ont subi une EASE. Une tomographie à faisceau conique (CBCT) a été réalisée en préopératoire et dans les quatre semaines suivant la fin du processus d’expansion. Une analyse de la dynamique des fluides computationnelle (DFC) a été réalisée sur vingt patients sélectionnés au hasard pour évaluer les modifications du débit de leurs voies respiratoires.Un bilan d’imagerie pré- et post-expansion a été réalisé chez cent patients (dont 67 hommes) d’un âge moyen de 35,0 ± 13,5 ans (17-64 ans). Quatre-vingt-seize patients (96 %) ont bénéficié d’une expansion réussie, définie comme une séparation de la suture médiopalatine d’au moins 1 mm, de l’épine nasale antérieure (ENA) à l’épine nasale postérieure (ENP). L’expansion de la cavité nasale était de 3,12 ± 1,11 mm au niveau de l’ENA, de 3,64 ± 1,06 mm au niveau de la première molaire et de 2,39 ± 1,15 mm au niveau de l’ENP. L’expansion zygomatique était de 2,17 ± 1,11 mm. Le rapport entre l’expansion dentaire et l’expansion squelettique était de 1,23 : 1 (3,83 mm : 3,12 mm) au niveau de la canine et de 1,31 : 1 (4,77 mm : 3,64 mm) au niveau de la première molaire. Après l’expansion, la simulation des voies respiratoires par DFC a montré un changement dynamique au niveau de l’ensemble des voies respiratoires. La pression négative moyenne s’est améliorée dans les voies nasales (de -395,5 ± 721,0 à -32,7 ± 19,2 Pa), les voies nasopharyngiennes (de -394,2 ± 719,4 à -33,6 ± 18,5 Pa), les voies aériennes oropharyngées (de -405,9 ± 710,8 à -39,4 ± 19,3 Pa) et les voies aériennes hypopharyngées (de -422,6 ± 704,9 à -55,1 ± 33,7 Pa). La vitesse moyenne du flux d’air dans les voies nasales a diminué de 18,8 ± 15,9 à 7,6 ± 2,0 m/s et de 4,2 ± 2,9 à 3,2 ± 1,2 m/s dans les voies oropharyngées. La vitesse n’a pas changé de manière significative dans les régions nasopharyngienne et hypopharyngienne.L’EASE entraîne une expansion de la suture médiopalatine, de l’ENA jusqu’à l’ENP avec un mouvement squelettique presque pur et un effet dentaire minimal. L’expansion du complexe nasomaxillaire a entraîné l’écartement des parois nasales latérales dans toute la cavité nasale. L’amélioration de la dynamique du flux d’air a été démontrée par une simulation DFC.

The strategy of fertility preservation (FP) in cervical cancer has been challenged for several years and a therapeutic de-escalation seems to be necessary. In this context, we evaluated the oncological, fertility and obstetric outcomes of surgical techniques performed in our centre for FP.This retrospective uni centric trial included 75 patients, managed at the Gustave Roussy Institute between 1995 and 2020, for cervical cancer (stage IB1 FIGO 2018) and having conducted a fertility preservation project after a complete pre-therapy work-up. The objective of this study was to understand our results on fertility and obstetrical outcomes and to correlate them with oncological data and finally to evaluate the evolution of our surgical practices.54 patients benefited from an extended trachelectomy and no lymph node involvement was found. 1 patient received a complementary treatment postoperatively which did not allow to preserve her fertility. The recurrence rate was 4.8% (4/75) with one death described. 31 pregnancies were obtained, representing a pregnancy rate of 50%. 74% of pregnancies were obtained spontaneously and 60% of pregnancies were carried to term.Our results are similar to those in the literature. Despite a fertility preservation project, only half of the patients were able to achieve a pregnancy.

Low-grade serous ovarian cancer is a distinct, slow-growing entity that affects mainly young women. The objective of this study was to describe the clinical characterisitics and survival outcomes of a population of patients suffering from advanced stage CSBG.A retrospective study was carried out in patients with advanced stage ovarian CSBG (FIGO IIIb-IV) who had complete macroscopic cytoreductive surgery, at Gustave Roussy Institut, Villejuif, between 2004 and 2017.Thirty-four patients were included, who were mainly young women (mean age 41.3 years), diagnosed at FIGO stage IIIC (91 %). The median follow-up was 41 months. Neoadjuvant chemotherapy was administered in 16 patients (47.1 %), and complete response never occurred. Upper abdominal surgical procedures were necessary in 90 % of cases and a bowel resection was performed in more than 80 % of cases. Over 90 % of patients received adjuvant chemotherapy followed by maintenance treatment with bevacizumab in over 40 % of cases. During follow-up, 9 (26 %) deaths occurred. Five-year overall survival was 70 % and disease-free survival was 20 %.CSBG of the ovary has a low chemosensitivity and requires maximum surgical management, which should be performed in expert centers.

Resume Le cancer de l’endometre est frequent chez la femme âgee et souvent associe a des comorbidites. Sa prise en charge en cas de situation metastatique et/ou de rechute necessite une approche multidisciplinaire. Les progres recents dans la comprehension de l’oncogenese et la classification moleculaire permettent d’envisager de nouvelles perspectives therapeutiques. Ces premieres recommandations etablies, selon la methodologie des recommandations pour la pratique clinique (RPC) Nice-Saint-Paul, visent a integrer les avancees moleculaires dans la prise en charge diagnostique et therapeutique. En 2020, le diagnostic histologique du cancer de l’endometre est base sur la morphologie et l’immunohistochimie incluant au minimum p53, les recepteurs aux œstrogenes et a la progesterone. La recherche d’une deficience du systeme de reparation des mesappariements de l’ADN (MMR) doit etre realisee de facon systematique pour toutes les tumeurs endometriales avancees a visee oncogenetique et theranostique. Elle peut etre recherchee dans un premier temps par une analyse en immunohistochimie avec les 4 marqueurs (MLH1, MSH2, MSH6, PMS2). Le traitement medical tient compte du type histologique, de la presence de recepteurs hormonaux et du profil de la patiente pour orienter vers une chimiotherapie (carboplatine–paclitaxel) ou une hormonotherapie (par exemple de type progestatifs) ; en cas d’une deficience MMR, la meilleure option est de proposer un essai d’immunotherapie. Dans le cadre de la prise en charge globale du cancer avance de l’endometre, la place de la radiotherapie (et a un moindre niveau, de la chirurgie) doit etre discutee, notamment en cas d’evolution exclusivement locoregionale ou de maladie oligometastatique.

Endometrial cancer is a common cancer in older women and is often associated with comorbidities. Management of metastatic disease and/or relapse requires a multidisciplinary approach. Recent advances in the understanding of oncogenesis and molecular classification of endometrial cancers offer new therapeutic perspectives. These first recommendations, established following the methodology of Nice-Saint-Paul recommendations for clinical practice (RPC), aims to integrate molecular advances in diagnostic and therapeutic management. In 2020, the histological diagnosis of endometrial cancer is based on morphology and immunohistochemistry, including at least p53, oestrogen and progesterone receptors. Deficiency in the DNA mismatch repair system (MMR) must be assessed in all advanced endometrial tumors for oncogenetic and theranostic purposes. It can be sought initially by an analysis in immunohistochemistry with the 4 markers (MLH1, MSH2, MSH6, PMS2). Medical treatment depends on histological type, presence of hormone receptors and patient's profile to refer to chemotherapy (carboplatin-paclitaxel) or hormone therapy (for example of the progestogen type); in the event of MMR-deficiency, immunotherapy trial is the best option. As part of overall management of advanced endometrial cancer, radiotherapy (and surgery in rare cases) must be discussed, in particular in the event of loco-regional only relapse or oligometastatic disease.

Faced to an undetermined ovarian mass on ultrasound, an MRI is recommended and the ROMA score (combining CA125 and HE4) can be proposed (grade A). In case of suspected early stage ovarian or fallopian tube cancer, omentectomy (at least infracolonic), appendectomy, multiple peritoneal biopsies, peritoneal cytology (grade C) and pelvic and para-aortic lymphadenectomy are recommended (grade B) for all histological types, except for the expansive mucinous subtype where lymphadenectomy may be omitted (grade C). Minimally invasive surgery is recommended for early stage ovarian cancer, if there is no risk of tumor rupture (grade B). Adjuvant chemotherapy with carboplatin and paclitaxel is recommended for all high-grade ovarian or Fallopian tube cancers, stage FIGO I-IIA (grade A). In case of ovarian, Fallopian tube or primitive peritoneal cancer of FIGO III-IV stages, thoraco-abdomino-pelvic CT scan with injection (grade B) is recommended. Laparoscopic exploration for multiple biopsies (grade A) and to evaluate carcinomatosis score (at least using the Fagotti score) (grade C) are recommended to estimate the possibility of a complete surgery (i.e. no macroscopic residue). Complete medial laparotomy surgery is recommended for advanced cancers (grade B). It is recommended in advanced cancers to perform para-aortic and pelvic lymphadenectomy in case of clinical or radiological suspicion of metastatic lymph node (grade B). In the absence of clinical or radiological lymphadenopathy and in case of complete peritoneal surgery during an initial surgery for advanced cancer, it is possible not to perform a lymphadenectomy because it does not modify the medical treatment and the overall survival (grade B). Primary surgery is recommended when no tumor residue is possible (grade B). After a complete first surgery, it is recommended to deliver 6 cycles of intravenous (grade A) or to propose intraperitoneal (grade B) chemotherapy, to be discussed with patient, according to the benefit/risk ratio. After a complete interval surgery for a FIGO III stage, the hyperthermic intra peritoneal chemotherapy (HIPEC) can be proposed in the same conditions of the OV-HIPEC trial (grade B). In case of tumor residue after surgery or FIGO stage IV, chemotherapy associated with bevacizumab is recommended (grade A).

National audience; Adjuvant chemotherapy with carboplatin and paclitaxel is recommended for all high-grade ovarian or Fallopian tube cancers, stage FIGO I-IIA (grade A). After a complete first surgery, it is recommended to deliver 6 cycles of intravenous (grade A) or to propose intraperitoneal (grade B) chemotherapy, to be discussed with patient, according to the benefit/risk ratio. After a complete interval surgery for a FIGO III stage, the hyperthermic intra peritoneal chemotherapy (HIPEC) can be proposed in the same conditions of the OV-HIPEC trial (grade B). In case of tumor residue after surgery or FIGO stage IV, chemotherapy associated with bevacizumab is recommended (grade A). For BRCA mutated patient, Olaparib is recommended (grade B).

National audience; Faced to an undetermined ovarian mass on ultrasound, an MRI is recommended and the ROMA score (combining CA125 and HE4) can be proposed (grade A). In case of suspected early stage ovarian or fallopian tube cancer, omentectomy (at least infracolonic), appendectomy, multiple peritoneal biopsies, peritoneal cytology (grade C) and pelvic and para-aortic lymphadenectomy are recommended (grade B) for all histological types, except for the expansive mucinous subtype where lymphadenectomy may be omitted (grade C). Minimally invasive surgery is recommended for early stage ovarian cancer, if there is no risk of tumor rupture (grade B). Laparoscopic exploration for multiple biopsies (grade A) and to evaluate carcinomatosis score (at least using the Fagotti score) (grade C) are recommended to estimate the possibility of a complete surgery (i.e. no macroscopic residue). Complete medial laparotomy surgery is recommended for advanced cancers (grade B). It is recommended in advanced cancers to perform para-aortic and pelvic lymphadenectomy in case of clinical or radiological suspicion of metastatic lymph node (grade B). In the absence of clinical or radiological lymphadenopathy and in case of complete peritoneal surgery during an initial surgery for advanced cancer, it is possible not to perform a lymphadenectomy because it does not modify the medical treatment and the overall survival (grade B). Primary surgery is recommended when no tumor residue is possible (grade B).

Faced to an undetermined ovarian mass on ultrasound, an MRI is recommended and the ROMA score (combining CA125 and HE4) can be proposed (grade A). In case of suspected early stage ovarian or fallopian tube cancer, omentectomy (at least infracolonic), appendectomy, multiple peritoneal biopsies, peritoneal cytology (grade C) and pelvic and para-aortic lymphadenectomy are recommended (grade B) for all histological types, except for the expansive mucinous subtype where lymphadenectomy may be omitted (grade C). Minimally invasive surgery is recommended for early stage ovarian cancer, if there is no risk of tumor rupture (grade B). Adjuvant chemotherapy with carboplatin and paclitaxel is recommended for all high-grade ovarian or Fallopian tube cancers, stage FIGO I-IIA (grade A). In case of ovarian, Fallopian tube or primitive peritoneal cancer of FIGO III-IV stages, thoraco-abdomino-pelvic CT scan with injection (grade B) is recommended. Laparoscopic exploration for multiple biopsies (grade A) and to evaluate carcinomatosis score (at least using the Fagotti score) (grade C) are recommended to estimate the possibility of a complete surgery (i.e. no macroscopic residue). Complete medial laparotomy surgery is recommended for advanced cancers (grade B). It is recommended in advanced cancers to perform para-aortic and pelvic lymphadenectomy in case of clinical or radiological suspicion of metastatic lymph node (grade B). In the absence of clinical or radiological lymphadenopathy and in case of complete peritoneal surgery during an initial surgery for advanced cancer, it is possible not to perform a lymphadenectomy because it does not modify the medical treatment and the overall survival (grade B). Primary surgery is recommended when no tumor residue is possible (grade B). After a complete first surgery, it is recommended to deliver 6 cycles of intravenous (grade A) or to propose intraperitoneal (grade B) chemotherapy, to be discussed with patient, according to the benefit/risk ratio. After a complete interval surgery for a FIGO III stage, the hyperthermic intra peritoneal chemotherapy (HIPEC) can be proposed in the same conditions of the OV-HIPEC trial (grade B). In case of tumor residue after surgery or FIGO stage IV, chemotherapy associated with bevacizumab is recommended (grade A).

Adjuvant chemotherapy with carboplatin and paclitaxel is recommended for all high-grade ovarian or Fallopian tube cancers, stage FIGO I-IIA (grade A). After a complete first surgery, it is recommended to deliver 6 cycles of intravenous (grade A) or to propose intraperitoneal (grade B) chemotherapy, to be discussed with patient, according to the benefit/risk ratio. After a complete interval surgery for a FIGO III stage, the hyperthermic intra peritoneal chemotherapy (HIPEC) can be proposed in the same conditions of the OV-HIPEC trial (grade B). In case of tumor residue after surgery or FIGO stage IV, chemotherapy associated with bevacizumab is recommended (grade A). For BRCA mutated patient, Olaparib is recommended (grade B).

Faced to an undetermined ovarian mass on ultrasound, an MRI is recommended and the ROMA score (combining CA125 and HE4) can be proposed (grade A). In case of suspected early stage ovarian or fallopian tube cancer, omentectomy (at least infracolonic), appendectomy, multiple peritoneal biopsies, peritoneal cytology (grade C) and pelvic and para-aortic lymphadenectomy are recommended (grade B) for all histological types, except for the expansive mucinous subtype where lymphadenectomy may be omitted (grade C). Minimally invasive surgery is recommended for early stage ovarian cancer, if there is no risk of tumor rupture (grade B). Laparoscopic exploration for multiple biopsies (grade A) and to evaluate carcinomatosis score (at least using the Fagotti score) (grade C) are recommended to estimate the possibility of a complete surgery (i.e. no macroscopic residue). Complete medial laparotomy surgery is recommended for advanced cancers (grade B). It is recommended in advanced cancers to perform para-aortic and pelvic lymphadenectomy in case of clinical or radiological suspicion of metastatic lymph node (grade B). In the absence of clinical or radiological lymphadenopathy and in case of complete peritoneal surgery during an initial surgery for advanced cancer, it is possible not to perform a lymphadenectomy because it does not modify the medical treatment and the overall survival (grade B). Primary surgery is recommended when no tumor residue is possible (grade B).

Ovarian carcinomas represent a heterogeneous group of lesions with specific therapeutic management for each histological subtype. Thus, the correct histological diagnosis is mandatory.References were searched by PubMed from January 2000 to January 2018 and original articles in French and English literature were selected.In case of ovarian mass suspicious for cancer, a frozen section analysis may be proposed, if it could impact the surgical management. A positive histological diagnosis of ovarian carcinoma (type and grade) has to be rendered on histological (and not cytological) material before any chemotherapy with multiples and large sized biopsies. In case of needle biopsy, at least three fragments with needles16G are needed. Histological biopsies need to be formalin-fixed (4% formaldehyde) less than 1h after resection and at least 6hours fixation is mandatory for small size biopsies. Tissue transfer to pathological labs up to 48hours under vacuum and at +4°C (in case of large surgical specimens) may be an alternative. Gross examination should include the description of all specimens and their integrity, the site of the tumor and the dimension of all specimens and nodules. Multiples sampling is needed, including the capsule, the solid areas, at least 1 to 2 blocks per cm of tumor for mucinous lesions, the Fallopian tube in toto, at least 3 blocks on grossly normal omentum and one block on the largest omental nodule. WHO classification should be used to classify the carcinoma (type and grade), with the use of a panel of immunohistochemical markers. High-grade ovarian carcinomas (serous and endometrioid) should be tested for BRCA mutation and in case of a detectable tumor mutation, the patient should be referred to an oncogenetic consultation.

Endometrial cancer is the fourth cause of cancer in women in France and is the second most common cancer of the gynecologic cancer after breast cancer with 7275 new cases in 2012. The incidence of this neoplasm tends to increase with population aging, diabetes and obesity's augmentation. In rare cases, a hereditary factor has been described: Lynch's syndrome. The therapeutic management of the patient depends on the endometrial biopsy which specifies the histological type and the histo-prognostic grade as well as the MRI which allow the tumor staging. Within the last decade, improvement in technologies such as genomic, transcriptomic and histological analyses, allowed the establishment of new and finer classifications of endometrial carcinomas. The latest classification proposed by The Cancer Genomic Atlas (TCGA), has been made routinely applicable through the international consortium TransPORTEC. It consists of 4 groups listed from good to poor prognosis: (1) ultra-mutated "POLE"; (2) hyper-mutated "MSI"; (3) low copy number "NSMP" and (4) high number of copies "TP53 mutated" (serous-like). This integrated characterization combined with mutational data opens new opportunities for therapeutic strategies.

Doublet chemotherapy with cisplatin is the reference for the treatment of recurrent cervical cancer. However, those tumors are little chemo-sensitive and overall survival remains poor. Moreover, because of pelvic irradiation, toxicities, especially hematologic toxicities, are increased and require a drug dose reduction. Finally, these treatments are rarely effective in radiation areas. Given all these elements, the development of new therapies is a prominent issue. This article reviews the results of the major targeted therapies in cervical cancer. Anti-EGFRs are disappointing despite of a strong biological rational. On the other hand, bevacizumab is the first targeted therapy to show a significant increase of overall survival. A major effort must be made in translational research for a better understanding of tumor biology of these tumors.

Uterine leiomyosarcoma is a rare disease with a poor prognosis. The rarity of this tumor needs a specialized management in tertiary reference centers in order to provide patients with optimal diagnostic, prognostic and therapeutic care. The pathological diagnosis relies on the presence of three characteristics in proliferating smooth muscle cells: necrosis, cytologic atypia and mitosis. Despite progress in the knowledge of the biology of these tumors, no oncogenic driver has been found. Prognosis depends mainly on the age of the patient, race, FIGO stage, mitotic index and hormonal receptor expression in the tumor. Surgery is one of the cornerstones of management and cytotoxic chemotherapy is the mainstay of treatment in metastatic disease with a potential role in the adjuvant setting. In locally advanced or metastatic disease, prognosis is poor with a median overall survival of about 12 to 14 months despite a 30% response rate to polychemotherapy regimens. Anti-angiogenics and hormonal therapy have a role to play in the setting of metastatic disease. It is mandatory to include such patients in clinical trials aiming to improve the therapeutic management of these patients. Multimodal therapy can improve the prognosis of selected patients too.

Chemotherapy is fundamental in the management of epithelial ovarian carcinomas both for early and advanced stages (rarely surgical treatment alone) and in almost every step of the disease. The reference schema combines carboplatin and paclitaxel intravenously. Intraperitoneal chemotherapy also proved its efficacy after complete surgery for advanced disease and should be reserved to trained teams due to its technical constraints and toxicity issues. Modalities of treatment in relapsed and progressive disease depend mainly on the free interval between this diagnosis and the last dose of platinum. Bevacizumab has proven its effectiveness in prolonging progression-free survival in 1st line setting in association with chemotherapy followed by maintenance and in case of relapse or progression both fore platinum sensitive or resistant disease. Finally, a better understanding of ovarian cancer biology will allow us to consider new molecular-targeted agents guided by the specific characteristics of each patient and each tumor.

Epithelial ovarian cancer frequently presents at an advanced stage where the cornerstone of management remains surgery and platinum-based chemotherapy. Unfortunately, despite sometimes dramatic initial responses, advanced ovarian cancer almost invariably relapses. Little progress has been made in the identification of effective targeted-therapies for ovarian cancer. The majority of clinical trials investigating novel agents have been negative and the only approved targeted-therapy is bevacizumab, for which reliable predictive biomarkers still elude us. Ovarian cancer is treated as a uniform disease. Yet, biological studies have highlighted the heterogeneity of this malignancy with marked differences in histology, oncogenesis, prognosis, chemo-responsiveness, and molecular profile. Recent high throughput molecular analyses have identified a huge number of genomic/phenotypic alterations. Broadly speaking, high grade serous carcinomas (type II) display significant genomic instability and numerous amplifications and losses; low grade (type I) tumors are genomically stable but display frequent mutations. Importantly, many of these genomic alterations relate to known oncogenes for which targeted-therapies are available or in development. There is today a real potential for personalized medicine in ovarian cancer. We will review the current literature regarding the molecular characterization of epithelial ovarian cancer and discuss the biological rationale for a number of targeted strategies. In order to translate these biological advances into meaningful clinical improvements for our patients, it is imperative to incorporate translational research in ovarian cancer trials, a number of strategies will be proposed such as the acquisition of quality tumor samples, including sequential pre- and post-treatment biopsies, the potential of liquid biopsies, and novel trial designs more adapted to the molecular era of ovarian cancer research.