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Ovarian cancer is recognized by the immunological system of its host. Initially, it is effective to destroy and eliminate the cancer. But gradually, resistant tumor cells more aggressive and those able to protect themselves by inducing immune tolerance will be selected. Immunotherapy to be effective should consider both components of immune response with an action on cytotoxic immune effectors and action on tolerance mechanisms. The manipulations of the immune system should be cautious, because the immune effects are not isolated. A theoretically efficient handling may simultaneously cause an adverse effect which was not envisaged and could neutralize the benefits of treatment. Knowledge of tolerance mechanisms set up by the tumor is for the clinician a prerequisite before they prescribe these treatments. For each cancer, the knowledge of its immunological status is a prerequisite to propose adapted immunological therapies., (Copyright © 2016 Elsevier Masson SAS. All rights reserved.)

Pregnancy is a temporary semi-allograft that survives for nine months. The importance of this event for the survival of the species justifies several tolerance mechanisms that are put into place at the beginning of pregnancy, some of which occur even at the time of implantation. The description of these mechanisms underlines the leadership of the trophoblast. The trophoblast is the conductor of the events, protects himself by expressing specific antigens and regulates the environment of the decidua according to the calendar of the events of the pregnancy The trophoblast and the decidual environment attract the effectors of immunity, almost all present in the decidua. The immunological atmosphere of the decidua evolves during the pregnancy modulating the level of activation of the immunological cells and adapting the level of activation to the stage of the pregnancy., (Copyright © 2014 Elsevier Masson SAS. All rights reserved.)

Objectives: Breast magnetic resonance imaging (MRI) has attained a solid position in the diagnosis of breast cancer but its benefit is still to be confirmed in the preoperative staging. The authors assessed the impact of preoperative breast MRI on surgical management of breast cancer in two university hospitals., Patients and Methods: This retrospective review was realized in two university hospitals and concerned all patients with breast carcinoma who had a surgical first therapy. We selected 89 patients who underwent preoperative breast MRI in the period between January 2008 and December 2009., Results: The sensitivity of breast MRI for detecting breast tumor was 95%. Fourteen percent of patients had a multifocal disease, 10% a multicentric disease and 2% a synchronous bilateral cancer. The correlation of radiological tumor size with histopathological size was r=0.68 in IRM compared to r=0.45 in conventional imaging (P<0.001). Nineteen additional biopsies were performed and 9.9% of false-positive findings were detected. Retrospectively, planned surgical management was altered in 9% of patients, resulted from use of breast MRI. Six patients had conversion of planned breast conservation to mastectomy and two patients underwent contralateral lumpectomy after discover synchronous bilateral cancer., Discussion and Conclusion: Breast MRI was very sensitive for the detection of breast carcinoma and improved local staging in almost 9% of patients. But, low specificity of this imaging requires a systematically validation of additional lesions by biopsy before surgical planning., (Copyright © 2014 Elsevier Masson SAS. All rights reserved.)

Objective: Radical hysterectomy is one of the treatment options for early stage cervical cancer. This surgery results in significant morbidity, especially urinary complications. The objective of the study is to determine the rate and predictive factors of parametrial involvement in early stage cervical cancer and to define a subset of patient at low risk for parametrial disease and potential applicant to less morbid surgery., Methods: This review reports recent retrospective and prospective studies and we show randomized trial concerning feasibility of no radical surgery., Results: Parametrial involvement rate in tumors <2 cm, without lymphovascular space invasion, with negative lymph nodes and depth of invasion <10mm is between 0 and 1.96%., Conclusion: This result, which suggests simple hysterectomy, is maybe adequate in this case. At present, no randomized trial allows to validate this hypothesis and to change present practices. Radical hysterectomy stays standard of surgical treatment of early stage cervical cancer., (Copyright © 2013. Published by Elsevier SAS.)

During pregnancy an environment allowing installation of tolerance toward the fetus is set up locally at the materno-fetal interface. Numerous effectors of immunity are involved in this tolerance (NK cell, T cell, Macrophages, dendritic cell). Specific mechanisms during pregnancy attract locally these immunological cells. In the decidua, they are educated toward tolerance. These mechanisms evolve during the pregnancy because at the end of the pregnancy, tolerance is broken to prepare and activate the labor. Ovarian tumors, after having surmounted the immunosurveillance, like trophoblast, chair the installation of a tolerance of their host facilitating the development of the disease. The blocking of these mechanisms of tolerance coupled with activation of mechanisms of defenses offer new perspectives in the treatment of the ovarian cancer. The authors suggest showing the analogies of the tolerance observed during ovarian cancer and pregnancy. The knowledge of the orchestration of the physiological mechanisms observed during pregnancy will offer new therapeutic targets., (Copyright © 2012 Elsevier Masson SAS. All rights reserved.)

Objective: Intrauterine device insertion is common. It is however not harmless and uterine perforation can be serious., Patients and Methods: Eleven cases of uterine perforation after intrauterine device insertion were listed at Tourcoing hospital between 2005 and 2009. They were analyzed to identify risk factors of uterine perforation and specify management., Results: The main symptom was pelvic pain (4 cases), pregnancy occurrence (3 cases) or inability to remove the IUD (2 cases). The intrauterine device was set during the first 9 months of post-partum in 7 cases, 2 patients were still breastfeeding. Seven patients underwent laparoscopy, 2 needed switch for laparotomy, one was treated by laparotomy only and one was lost of follow-up., Discussion and Conclusion: Incidence of uterine perforation after IUD insertion ranges from 0,1 to 3/1000. Pelvic pain is the most revealing symptom. Fifteen percent of perforations complicate with adjacent organ lesion. Perforation incidence seems greater if the intrauterine device is set during the 6 first weeks of post-partum and breastfeeding, but non influenced by operator practical experience. Ultrasound follow-up of patients carrying intrauterine device is controversial. Facing a suspicion of ectopic intrauterine device, pelvic ultrasound examination is the first step imaging modality and using 3D could be useful. If it fails to localize the intrauterine device, an abdominal X-ray must be performed. Ectopic intrauterine device removal is recommended., (Copyright © 2012 Elsevier Masson SAS. All rights reserved.)

Objectives: Ductal carcinoma in situ (DCIS) is a common breast lesion (10% of breast cancers). In most of the cases the standard treatment is a partial mastectomy combined with adjuvant irradiation. However, when positive margins (<2mm) occur, surgical re-excision is necessary. The purpose of our study was to determine the rate of reoperation for positive margins in DCIS and identify potential preoperative risk factors of unhealthy margins., Patients and Methods: This is a retrospective study of 63 patients. We collected cases of DCIS at the Lille and Valenciennes' hospitals from the 1st of January 2007 till the 1st of January 2012., Results: Fifty patients have had a partial mastectomy and 28 patients (56%) have had one or two complementary interventions to get healthy resection margins. The pathologic tumor size (>10mm) appears to be a risk factor for positive margins., Discussion and Conclusion: Few studies were aimed at identifying risk factors for unhealthy margins for DCIS. The main risk factors found in the literature are: the presence of comedonecrosis, tumor greater than 10mm, a palpable tumor, the absence of a preoperative biopsy, the low-grade lesions. Our study confirmed the influence of tumor size greater than 10mm as a risk factor for positive margins., (Copyright © 2013 Elsevier Masson SAS. All rights reserved.)

Pregnancy is a temporary semi-allograft that survives for nine months. The importance of this event for the survival of the species justifies several tolerance mechanisms that are put into place at the beginning of pregnancy, some of which occur even at the time of implantation. The presence of multiple tolerance mechanisms and the richness of the means employed underline the central importance of the trophoblast. Understanding these mechanisms, and in particular, their integration into an overall scheme, enables the anomalies encountered in certain pathologies of pregnancy to be placed into context. Understanding these mechanisms and their interruption at the end of pregnancy should improve our understanding of disappointing results from current immunological treatments facilitate the implementation of new prophylactic and therapeutic strategies., (Copyright © 2012. Published by Elsevier Masson SAS.)

More and more perimenopausal and menopausal women seek an alternative to hysterectomy because they desire future pregnancy or wish to retain their uteri even if they have completed childbearing. Myomectomy may be an option. We can't know the evolution of leiomyomas. Hysteroscopic myomectomy is the treatment of submucous fibromas. Recurrence and subsequent surgery occurs in 16 to 21 % of cases. Intramural and subserousal myomas can be treated by myomectomy. Myomectomy should be performed laparoscopically because of shorter hospital stay, faster recovery and reduced postoperative pain. Second surgery is needed in 4-16 % of patients. If hysterectomy is performed, it should be by vaginal or laparoscopic route. There is no difference in perioperative morbidity between hysterectomy and myomectomy. Intra- and postoperative complications are similar between myomectomy and hysterectomy. Hysterectomy may be prefered if there is risk factor of malignancy or if the fibroma is discovered or has a rapid growth after menopause., (Copyright © 2011 Elsevier Masson SAS. All rights reserved.)

Purpose: An update on the management of invasive cervical cancer (from stage IB) diagnosed during pregnancy with reference to the recent French guidelines., Patients and Methods: We retrospectively analyzed patients for whom invasive cervical cancer was diagnosed during pregnancy and managed jointly by Jeanne-de-Flandres and Roubaix maternity and by Oscar-Lambret cancer center between 2002 and 2009., Results: Five patients were included: four stage IB1, and one stage IB2. Five pregnancies resulted in the birth of six alive children. Three patients received neoadjuvant chemotherapy during pregnancy. One patient had a laparoscopic pelvic lymphadenectomy in first trimester. Two laparoscopic extraperitoneal paraortic lymphadenectomy have been made. The mean time of survey is 47.5 months (12-94 months). One patient died of her cancer., Conclusion: The diagnosis of cervical cancer during pregnancy involves the same therapeutic guidelines in the absence of pregnancy. The laparoscopic pelvic lymphadenectomy (up to 20 to 24 weeks of gestation) is crucial in the therapeutic treatment for tumors less than 4cm. Neoadjuvant chemotherapy is used during pregnancy for patients refusing medical termination of pregnancy., (Copyright © 2011 Elsevier Masson SAS. All rights reserved.)

For a long time, the conventional view was that the fetus and maternal vascular system are kept separate. In fact there is a two-way traffic of immune cells through the placenta and the transplacental passage of cells is in fact the norm. The fetal cells can persist in a wide range of woman's tissue following a pregnancy or an abortion and she becomes a chimera. Fetal cells have been found in the maternal circulation and they were shown to persist for almost three decades in humans, thus demonstrating long-term engraftment and survival capabilities. Microchimerism is a subject of much interest for a number of reasons. Studies of fetal microchimerism during pregnancy may offer explanations for complications of pregnancy, such as preeclampsia, as well as insights into the pathogenesis of autoimmune disease which usually ameliorates during pregnancy. The impact that the persistence of allogenic cells of fetal origin and the maternal immunological response to them has on the mother's health and whether it is detrimental or beneficial to the mother is still not clear. Although microchimerism has been implicated in some autoimmune diseases, fetal microchimerism is common in healthy individuals. On the beneficial side, it has been proposed that genetically disparate fetal microchimerism provides protection against some cancers, that fetal microchimerism can afford the mother new alleles of protection to some diseases she has not, that fetal microchimerism can enlarge the immunological repertoire of the mother improving her defense against aggressor. Fetal cells are often present at sites of maternal injury and may have an active role in the repair of maternal tissues., (Copyright © 2011 Elsevier Masson SAS. All rights reserved.)

There is a two-way traffic of cells through the placenta during the pregnancy (feta and maternal microchimerisms). Fetal cells migrate in the maternal body where they are present long after birth. The fetal microchimerism may be deleterious for the mother when implicated in the induction of autoimmune diseases and of repeated abortion. Usually fetal microchimerism is beneficial for the mothers. Fetal cells can repair damaged tissues, transmit paternal resistance alleles, improve the directory of T cell receptors. In cancer, the effects are more contrasted, beneficial and protective for certain cancers, harmful and favouring the development for the others. The phenomenon of fetal and maternal microchimerisms inspires numerous questions and offers new perspectives on the biology of pregnancy and cancer, on pathogenesis of auto-immunity, of the transplantations, without forgetting the biology of the heredity because these cells could bring resistance or risk alleles for some diseases from the father towards the mother through the fetus, through the mother to the fetus, from the first fetus of a first pregnancy to the next fetus through the woman., (Copyright © 2011 Elsevier Masson SAS. All rights reserved.)

The use of mesh for pelvic organ prolapse repair through the vaginal route has increased within the last decade. The main objective is to improve anatomical results (based on the superiority of sacropexy with meshes when compared to vaginal traditional surgery), with the advantages of the vaginal route. An increasing number of cohort series and randomized control trials have been published. There is level-1 evidence that the use of mesh for the treatment of cystocele through the vaginal route improves anatomical results when compared to traditional surgery. The rates of complications between these two techniques seem equivalent, even for de novo dyspareunia., (Copyright © 2011 Elsevier Masson SAS. All rights reserved.)

Objectives: Twenty-two uterine carcinosarcomas were treated and followed in two centers over 10 years. We wanted to describe them and review the literature on the subject., Patients and Methods: We describe all uterine carcinosarcomas treated in Lille, over 10 years, both in department of gynecology, Hospital Jeanne-de-Flandre (11 patients), and in department of gynecologic oncology of Centre Oscar-Lambret (11 patients)., Results: For the 22 patients included, we give age at time of diagnosis, body mass index, pre and post surgical histology, details of surgical treatment, adjuvant treatment and evolution of the pathology. Mean age at time of diagnosis was 69.6. Sixty-eight percent of patients had overweight or obesity. Revealing symptoms were in 91% of cases post-menopausal meno- or metrorrhagias. Preoperatively, histology had an important number of false negative and, 57% of diagnoses were ignored in our study. All patients had first intention surgery, only 54% were yet at an early stage. Sixteen had association radiotherapy, eight of chemotherapy, two declined any adjuvant treatment. Ten patients died with a mean survival of 12.9 months, eight had a good evolution still at 35 months, two had recent pelvic relapse, two were lost to follow-up., Conclusion: Uterine carcinosarcomas are rare, aggressive, yet not very well known tumors. First line treatment will be surgery with peritoneal cytology, hysterectomy, bilateral adnexectomy, pelvic and sometimes lumbo-aortic lymphadenectomy, omentectomy, peritoneal biopsies. Adjuvant chemotherapy has shown its interest in this type of tumor. Radiotherapy is still debated., (Copyright © 2010 Elsevier Masson SAS. All rights reserved.)

Unlabelled: As maternal age at the time of pregnancy continues to increase and the incidence of breast cancer is raising, the incidence of pregnancy associated with breast cancer can be expected to increase. A review of the literature was performed to help identify optimal treatment strategies., Methods: a search of electronic databases between 1967 and the present identifies studies reporting breast cancer associated with pregnancy. There is a paucity of prospective studies regarding diagnosis and treatment of breast cancer during pregnancy. Women diagnosed with breast cancer during pregnancy have similar disease characteristics to age-matched controls. Current evidence suggests that diagnosis may be carried out with limitations regarding staging. Surgical treatment may be performed as for the non-pregnant women. Radiotherapy and endocrine or antibody treatment should be postponed until after delivery. Chemotherapy is allowed after the first trimester. Breast cancer in pregnancy is an uncommon phenomenon but one which poses dilemmas for patients and their physicians. A multidisciplinary approach is recommended for optimal clinical decision making. But physicians should be aggressive in the workup of breast symptoms in the pregnant population to expedite diagnosis.

From the Automated Endoscopic System for Optimal Positioning (AESOP), a robotic arm which operates the laparoscope, to the robots Zeus and da Vinci, robotic assistance in gynaecological endoscopic surgery has continuously evolved for the last fifteen years or so. It has brought about new technical advancements: the last generation robots offer a steady three-dimensional image, improved instrument dexterity and precision, higher ergonomics and comfort for the surgeon. The da Vinci robotic system has been used without evincing any specific morbidity in various cases, notably for tubal reanastomosis, myomectomy, hysterectomy, pelvic and para-aortic lymphadenectomy or sacrocolpopexy amongst others. Robotic assistance in gynaecology is thus feasible. Like conventional laparoscopic surgery, it allows decreased blood loss and morbidity as well as shorter hospital stay, as compared to laparotomy. It might indeed allow many surgical teams to perform minimally invasive surgical procedures which they were not used to performing by laparoscopy. Randomized prospective studies are needed to define its indications more precisely. Besides, its medico-financial impact should be evaluated too.

Objective: Fluorescence diagnosis is still undeveloped in gynaecology. In order to diagnose and localize squamous intraepithelial lesion (SIL) of the cervix, a new method improving the low specificity of colposcopy would be useful. The goal of this study was to assess the feasibility and safety of colposcopic fluorescence diagnosis of SIL after topically application of methyl aminolevulinate (MAL)., Patients and Methods: Patients with histologic proved cervical intraepithelial neoplasia (CIN) and planned for loop electrosurgical excision procedure (LEEP) under general anesthesia were included in a prospective study. Before general anesthesia, a thick layer of MAL (Metvix-160 mg/mL cream) was applied on the cervix for 35-150 min. Fluorescent colposcopic inspection of the cervix was performed using a rigid 10-mm laparoscope inserted in the vaginal cavity and connected to D-light AF system (Karl Storz Endoskope, Tuttlingen Germany). In order to confirm neoplasic status, fluorescent foci underwent directed punch biopsy(ies)., Results: Fourteen patients were included in the study. Colposcopic fluorescence imaging revealed red fluorescent foci in 71.4% of cases (10/14) (neoplasic status of fluorescent foci was confirmed in 80%). Concerning MAL, the mean of application time was 73 min (35-150). Two cases presented a false-positive fluorescence and four cases of false-negative fluorescence. For all cases of false-negative fluorescence, application time of MAL was less than 60 min. We observed no systemic or local toxicity of MAL application in any group., Discussion and Conclusion: Using topical application of MAL to the cervix, we demonstrated that fluorescence diagnosis of SIL is feasible. This study justifies the further development of fluorescence imaging that combines classical white light colposcopy with the use of a photosensitizer.

In patients with dysfunctionnal uterine bleeding, endometrial hypertrophy or endometrial hyperplasia without atypie, the curettage is the only surgical conservative treatment which allows preservation of fertility. Its efficacy is limited to about 50%. In women without wish for further childbearing, endometrial destruction techniques are effective with high satisfaction levels. Second generation devices should be preferred because they are as effective as first generation techniques, but are easier and faster to perform with less complications. There is no indication for systematic use of pre operative thinning agents. Endometrial destruction techniques are an alternative to hysterectomy that should be offered to women with heavy menstrual bleeding, because there are shorter operation time and hospital stay, earlier recovery and reduced post operative complications. The possibility of further surgery should however be discussed pre-operatively. In case of hysterectomy, abdominal route is not recommended, and vaginal or laparoscopic routes are preferred.

Vulvar pathology is located at the border between dermatology and gynaecology. The gynaecologist is concerned by VIN (vulvar intraepithelial neoplasia) lesions as patients meet them for that problem. He makes distinction with dermatologic lesions so as to refer proper patients to dermatologists. A recent classification of VIN has a major interest. One individualizes two kinds of precancerous lesions. The first one is lichen sclerosis with dermatologic treatment by dermocorticoids and the other aetiology is HPV infection with frequent association with cervical localisation. Gynaecologists are more familiar with this second aetiology. Thus, they have to (i) check for VIN, (ii) know their appearance and how the diagnosis can be made by biopsy, (iii) precise the aetiology, (iv) appreciate the severity of the disease, (v) discuss which treatment is indicated: destruction or surgery.

Photodynamic therapy (PDT) is a specific anticancer treatment that received significant interest in several medical and surgical disciplines. The technique is based on (i) the application of the photosensitizer that accumulates in a variable time in the neoplasic lesions and on (ii) excitation (by light whose wavelength coincides with the absorption peak of the photosensitizer) that (iii) finally causes the destruction of the lesion. This technique allows a minimally-invasive, effective and targeted treatment of some gynecological diseases. Experimental and/or clinical studies have been conducted on vulvar intraepithelial neoplasia, cervical intraepithelial neoplasia, ovarian cancer, breast cancer, dysfunctional uterine bleeding, endometriosis and vulvar lichen sclerosus. We aim to present the principles of PDT and to expose the main indications and ways of research of this technique in gynecology today.

Ovarian cancer represents 4500 new cases a year in France and the prognosis of such tumor is not yet clear, even for the early stages. This is notably owing to the amount and size of peritoneal tumor residual. Recently, five therapeutic trials were published concerning the intra-peritoneal chemotherapy of ovarian cancer stage III in patients to whom an optimal debulking surgery had been done. These studies were variable in there outcome showing on the one hand, either the absence of significant difference or a significant lengthening of both total life duration and life without recurrence during the period of treatment with intra-peritoneal chemotherapy. On the other hand, there was a significant increase in hematological toxicity and temporary impairment of the quality of life during intra-peritoneal treatments. There were also complications linked to the intra-peritoneal catheter, which led to the termination of the treatment protocol in some cases. However, results showed a mattering benefit of survival in spite of a notable rate of incomplete treatment protocols. These results have demonstrated the necessity to consider the intra-peritoneal adjuvant chemotherapy as a treatment option in patients with epithelial ovarian cancer stage III. Patients must be highly selected and well counseled, in order to go for this treatment option after receiving optimal debulking surgeries.

Dermoid cyst is the most frequent benign ovarian tumor. Its spontaneous or more frequently iatrogenic intraperitoneal rupture may lead to a chemical peritonitis. This is a rare complication but with a potentially dangerous issue. We report a case of a patient who developed chemical peritonitis after laparoscopic management of ovarian dermoid cysts. Three further interventions, associated with systemic anti-inflammatory treatment, were necessary to resolve symptoms completely. On the basis of this case, we aim to re-access the characteristics of dermoid cysts and highlight in particular the potential complication of chemical peritonitis and the following attitude to avoid this.

Unlabelled: The potential of fluorescence diagnosis (FD) is still undeveloped in gynaecology. In order to diagnose and localize squamous intraepithelial lesion (SIL) of the cervix, a new method improving the low specificity of colposcopy, would be useful., Objective: The goal of this study was to assess the feasability and safety of colposcopic FD of SIL after topicaly application of methyl aminolevulinate (MAL)., Materials and Methods: Patients with histologic proved cervical intraepithelial neoplasia (CIN) and planned for loop electrosurgical excision procedure (LEEP) under general anesthesia, were included in a prospective study. Before general anesthesia, a thick layer of MAL (Metvix(®)-160mg/mL cream) was applied on the cervix for 35-150min. Fluorescent colposcopic inspection of the cervix was performed using a rigid 10-mm laparoscope inserted in the vaginal cavity and connected to D-light AF system (Karl Storz Endoskope, Tuttlingen Germany). In order to confirm neoplasic status, fluorescent foci underwent directed punch biopsy(ies)., Results: Fourteen patients were included in the study. Colposcopic fluorescence imaging revealed red fluorescent foci in 71.4% of cases (10/14) (neoplasic status of fluorescent foci was confirmed in 80%). Concerning ME-ALA, the mean of application time was 73min (35-150). Two cases presented a false-positive fluorescence and four cases of false-negative fluorescence. For all cases of false-negative fluorescence, application time of MAL was less than 60min. We observed no systemic or local toxicity of MAL application in any of the groups., Conclusion: Using topical application of MAL to the cervix, we demonstrated that FD of SIL is feasible. This study justifies the further development of fluorescence imaging that combines classical white light colposcopy with the use of a photosensitizer.

Objective: With personal results and a review of the literature, we report the eventual interest of surgical staging in malignant ovarian germ cell tumours., Patients and Methods: This was a retrospective study of 36 patients (21.5-[8-61]) with malignant ovarian germ cell tumours between January 1984 and December 2004. There were 4 groups: no 1--dysgerminoma only, no 2--immature teratoma, no 3--malignant ovarian germ cell tumours with secretion. All the patients had a minimal follow up of 18 months after treatment. We reported conservative or non-conservative surgery, if surgical staging was made and description of eventual neoadjuvant or adjuvant chemotherapies and finally the recurrences and deaths., Results: Stages of FIGO were: group 1--IA n=2, IC n=2, IIB n=1, IIIA n=2, IIIC n=3; group 2--IA n=3 (G1, G2, G2), IC n=1 (G3); group 3--IA n=8, IC n=4, IIA n=1, IIIA n=1, IIIB n=3, IIIC n=5. Three patients had neoadjuvant chemotherapy. All the patients had cytoreductive surgery (conservative surgery n=31) with staging in 15 cases. Twenty-six patients had adjuvant chemotherapy. Five years global survival was 92%., Discussion and Conclusion: Surgery in a young patient with malignant ovarian germ cells tumours must be conservative (adnexectomy) (preserving fertility and because of good prognostic). In case of stage IA with part of dysgerminoma and/or immature teratoma and/or embryonal carcinoma certified by surgical staging, strict follow up could be organized (clinic, radiology, AFP, HCG). In case of more than stage IA, chemotherapy is indicated after conservative surgery and surgical staging.

Objectives: To assess the feasibility and morbidity of surgical management by combined laparoscopic and vaginal approach after cervical cancer diagnosed at the time of simple hysterectomy., Patients and Methods: From 2000 to 2005, 10 patients were referred with occult cervical cancer discovered after simple hysterectomy. All these patients had laparoscopy for surgical staging., Results: Eight on ten patients had complete laparoscopic staging: pelvic lymphadenectomy (N=8), radical colpectomy (N=5). Operative time, pelvic lymph nodes resected, postoperative stay were respectively 261.3 minutes (200-400), 27 (23-38), 4.4 days. There were 2 symptomatic lymphocysts. Pelvic lymph nodes were positive for 1 patient with negative paraaortic nodes. Residual disease was present in 2 cases: 1 parametrial and vaginal involvement, 1 ovarian metastasis. 5 patients had adjuvant treatment: 2 combined pelvic external radiotherapy and brachytherapy, 1 pelvic external radiotherapy, 1 pelvic concurrent chemoradiation and 1 brachytherapy only. Two on ten patients needed a laparoconversion, one for ovarian involvement and one for technical failure. With a median follow-up of 29.7 months (4-63), 3 patients recurred. 3 patients recurred above 5 patients with pelvic lymphadenectomy but without parametrectomy versus no recurrence above 5 patients with pelvic lymphadenectomy and parametrectomy., Discussion and Conclusion: Surgical staging of occult cervical cancer discovered after simple hysterectomy is necessary for indication of adjuvant treatment. Laparoscopy combined with vaginal surgery is feasible and safe, inducing fewer adhesions which is important for adjuvant radiotherapy. The realization of a radical parametrectomy seems to offer a local control of the disease and a decrease in the risk of recurrence, which need to be confirmed by conducting a study with more patients. This emphasize the necessity of creating a national record to register all women managed for occult cervical cancer.

Adhesion barriers are intraperitoneal agents, solid or fluid, developed in order to prevent postoperative adhesions. In this article, we evaluate the efficiency of these new barrier agents for adhesion prevention in gynaecologic surgery, undertaking a review of controlled clinical trials published. Several human clinical trials demonstrated the safety and efficiency of both Interceed and Seprafilm. As far as other barrier agents are concerned, data are still insufficient to recommend them for clinical use. There is a need for other randomised controlled trials in order to evaluate functional efficiency of anti adhesion agents.

The authors describe a case report of a tubal choriocarcinoma occurring in women of 32 years old, 2 years after her last pregnancy. The patient was treated by laparoscopic salpingectomy and polychemotherapy. Metastatic pulmonary micronodules were diagnosed at thoraco-abdomino-pelvic tomodensitometry. Patient's recovery was complete with an uneventfull follow-up at 3 years. The association of surgical treatment and chemotherapy used under the guidelines of the FIGO score improves patient's outcome.

Relationship between infertility and endometriosis is still controversial. Many mechanisms have been reported such as anatomical disorders, biologic and cytological modifications of peritoneal liquid, functional ovarian and endometrial disorders, reduced embryo quality. Management of infertility related to endometriosis is difficult and no consensus has been published yet. Following recent clinical data, therapeutic strategies are discussed.

Context: The validity of the recommendations is based on their actualisation as well as on the quality of the initial elaboration process. Therefore the "Standards, Options and Recommendations" (SOR) from the National French federation of comprehensive cancer centres (FNCLCC) has set up a literature monitoring process., Objectives: To identify new data, which are likely to modify existing recommendations, evaluate their impact and inform potential users on their validity., Methods: The monitoring process is based on 3 main steps lead in collaboration with experts: collect data, select and classify information and analyse information. Analysis of information consists of comparing the conclusions of new data with the conclusions of the initial report and then to identify the recommendations that need to be updated., Results: This article presents the 2005 monitoring report concerning "the use of positron emission tomography with FDG in the management of breast cancer, ovarian cancer and uterin cancer". Following the monitoring process,all the existing recommendations (initial report from 2003) are still valid. However three modifications have been proposed by the working group: 1) increased level of evidence concerning the use of PET-scan for suspicion of local or metastatic recurrence (option, level of evidence: A); 2) a new option for the use of PET-scan for revealed cervix cancer recurrence, especially for the therapeutic decision strategy (level of evidence: B2); and 3) new formulation (less strict) of the recommendation concerning the use of PET-scan in the management of endometrial cancer.

Endometriosis of the urinary tract (bladder and/or ureter) is rare and concerns 1-2% of cases of endometriosis. Surgical management is usually mandatory. Rate of peri operative morbidity is low. There is a risk of functional (dysuria, chronic hypogastric pains, imperiosity) and anatomical recurrences (0-15 and 0-10% respectively). Surgical treatment of bladder and/or ureteral endometriosis requires informed consent of patients and multidisciplinary management.

The authors propose to report progress on the use of the CA 125 serum assay. It affects three situations: screening, diagnosis and the follow-up of the patients dealt with ovarian tumour either of benign or malignant nature. For each situation the interest and the relevance of CA 125 assay will be approached.

Uterine intravenous leiomyomatosis is a rare benign tumor. We report the case of a 41-year-old woman, with no history, who presented an abdominopelvic mass arising from the uterus. Histological examination revealed uterine intravenous leiomyomatosis. The specificity of this tumor is hormonodependency and potential vascular extension.

Ovarian immature teratoma is a malignant germ cell tumor and represents less than 1% of ovarian malignant tumors. Tissues are derived from the three germ layers (endo-, meso- and ectoderm). Tumor grading is based on the amount of immature neuroepithelium present. The prognosis is directly correlated to histologic grade. Rapid growth leads to large tumors with an early diagnosis. Therapeutic management is balanced between adjuvant chemotherapy and surgery alone. Nevertheless, as immature teratoma mostly occurs in young women, the main objective is to preserve fertility.

Uterine arteriovenous malformation is a rare condition. We report a case with acquired arteriovenous malformation arising from the left uterine artery. She was diagnosed by color Doppler ultrasound and treated with a selective uterine artery embolization.

The diagnosis of malignant melanoma metastatic to the ovary is rare. The primary lesion can be followed by metastasis site after few years. We describe the case of a 31 year-old woman who presented an acute pelvic pain in relation with a right ovarian cyst. This patient presented many metastatic melanoma few years ago. The ovarian metastatic diagnosis is strongly suspected by the use of preoperative magnetic resonance imaging. The operating piece immunohistochemical studies demonstrated the positivity for S-100 protein, HMB-45 and negativity for keratin in cytoplasm cells. The surgical treatment (right salpingo-oophorectomy) would be followed by chemotherapy. The patient had a good postoperative recovery. She is in good health at six months.

Introduction: Phyllodes tumors of breast are rare and usually benign. These are histologically fibro-epithelial tumors similar to fibroadenomas. Histological confirmation on the operative specimen is required to establish the diagnosis and histological pronostic of phyllode tumors., Materials and Methods: We reviewed 8 cases of phyllodes tumors and the literature to report the circumstances of occurrence of these tumors, and their specific clinical diagnosis, therapeutic, prognostic features., Results: 62.5% of patients were nulliparous. The mean age at diagnosis was 33.4 years. Mean tumor size was 3.75 cm. Tumours predominated on the right side (87.5%) and upper-outer quadrant (62.5%). Imaging findings were helpful for diagnosis. Aspiration cytology demonstrated the phyllode tumor in 43% of patients. Wide tumorectomy was performed in seven patients. One patient underwent mastectomy and radiotherapy and chemotherapy. The recurrence rate (37.5%) justifies wide margin excision. There were no deaths in our series., Discussion: and conclusion. These results together with those reported in the literature show that the loco-regional and general spread depends on margin surgery.

Objective: To keep the pneumoperitoneum and the tightness of the abdominal and pelvic cavity during a laparoscopy, the sheaths of trocar are provided with a device (valvule, membranes etc.) inducing a friction during the handling of the instrument. The objective of this article is to analyse friction from different types of trocar's port., Materials and Methods: We present here the experimental results obtained during a testing bench of three different trocar sheaths. The mechanism of tightness of the first trocar sheath is made of a fine membrane associated to a valve, of a thick membrane for the second trocar sheath, whereas the third trocar sheath is made of two membranes, a fine and a thick, associated to a valve. After reporting the experimental device and the analytic model adopted to describe the relationship between the measured physical parameters, we lay out our results. The identification of parameters of this model makes it possible to objectively compare the three trocars., Results: Our results revealed that, under experimental conditions, the amplitude of friction was significantly lower with trocar's port provided with a valve and a fine membrane than with both other ports (fivefold weaker)., Discussion and Conclusion: We evoke the importance of the possible disruption brought by these frictions while referring these values to those of other measurements concerning interactions between instrument and organs. These different behaviours of the material could have some consequences in choosing the tools for the performance of precise gestures.

A case of primary choriocarcinoma of the ovary in a 32-year-old woman, 1 month after a voluntary interruption of pregnancy, is reported. A review of the literature shows that this tumour is rare and the distinction between a gestational and a non-gestational choriocarcinoma is difficult. The distinction between these two diagnoses and specific treatment are discussed.

The use of fluorine-18 fluorodeoxyglucose (FDG) in positron emission tomography (PET) is a major advance in imaging in the recent past. Its use in breast and gynaecologic cancers is not well established and needs to be discussed for each patient. This discussion must rely on a better knowledge of potential interests as well as of the limits of metabolic or logistic limits of PET.

Objective: Rate scales are used to analyse urinary incontinence. There are many scales making it difficult to compare the different studies of urinary incontinence. The purpose of this study was to evaluate and compare the rate scales pertaining specifically to urinary incontinence., Patients and Method: A review of the literature was performed for publications specifically addressing rate scales of urinary incontinence. Each scale was evaluated using the following four criteria: principal characteristics (reference source, number of items addressed, scoring method, language), objectives (type of incontinence, severity and quality of life measures), psychometric properties (scientific validity, reliability and responsiveness) and linguistic validation., Results: Thirteen scales were identified. These were divided into two groups: (1) those based on "classifications" and (2) those based on specific questionnaires. Scales based on classifications were not precise and are never scientifically validated. Scales based on questionnaires were more elaborate and more detailed; nevertheless, the study of their psychometric properties was often incomplete., Discussion and Conclusion: Classification-based rate scales are inadequate to analyse urinary incontinence. Questionnaire-based rate scales are superior, but at minimum, they should address the previously stated objective and psychometric criteria. The choice of questionnaire should depend on whether it is to be used in clinical practice or for research protocol.

Breast cancer is certainly not preventable at the same degree as lung cancer is by avoiding cigarette smoking or bladder cancer by avoiding exposure to some specific professional carcinogens. Despite the increased availability of screening mammography and the use of adjuvant chemotherapy, breast cancer remains a major cause of morbidity and mortality in women. Chemoprevention could be one of the possible weapons to decrease the morbidity and the mortality due to breast cancer. Experimental, epidemiological and clinical data suggest that one can prevent occurrence of breast cancer. The results of five trials including more than 25,000 patients comparing the effectiveness of tamoxifen with a placebo were published. The results of these trials, at first sight, do not agree. Only in the USA, the results of the five trials have led to licence tamoxifen for chemoprevention of breast cancer. But the Food and Drug Administration stresses the fact that the noxious side effects are too numerous for this molecule to be prescribed with all the patients. It must be reserved for the women presenting an increased risk. The means of identifying the women at increased risk are not yet perfect.

Objectives: The aim of this study was to analyse the cytological history of women presenting with invasive cervical cancer., Material and Methods: Retrospective study of 148 patients treated for invasive cervical cancer in three hospitals of the North Pas de Calais in France., Results: The average age of patients was 49 (26-86). Squamous carcinomas represented 81% of cases (120/148), adenocarcinomas 17% (25/148) and adenosquamous carcinomas 2% (3/148). 36.5% of patients (54/148) had never had a Pap smear. 34.5% (51/148) had had an occasional Pap smear (the last one dated of more than three years). 8.1% (12/148) were lost for follow up after a positive Pap smear. 3.4% (5/148) were treated for cervical dysplasia less than three years before the diagnosis of the cervical cancer. 17.5% (26/148) had had a Pap smear reported as negative less than three years before the diagnosis of the cervical cancer. In this last group, squamous carcinomas represented 57.7% of cases (15/26), adenocarcinomas 38.5% (10/26) and adenosquamous carcinomas 3.8% (1/26). 18 Pap smears of 26 reported as negative less than three years before the diagnosis of the cancer were reviewed. These Pap smears came from 11 patients presenting with squamous carcinoma and seven other presenting with adenocarcinoma. After review, 15 Pap smears were reported as false negatives and two as true negatives. The review was not possible in one case., Conclusion: In this study, the failures of cervical cancer screening were essentially attributed to the lack or the insufficiency of screening and the existence of false negatives of the cytology.

A practical review of tumor markers, particularly CA125 is proposed. The questions are: what is the role of CA125 assay in cancer screening programs, can preoperative CA125 level predict the benign or malignant nature of an adnexal anomaly, can postoperative CA125 predict the quality of surgical resection of cancer of the ovary?

HPV types are carcinogenic in cervical cancer. This view is supported by epidemiological and biological evidence. Knowledges of HPV gene expression, of natural history of cervical HPV infection and neoplasia and of tumoral antigenic expression have lead to develop two strategies for vaccine development: 1-Prophylactic vaccines of HPV infections. 2-Therapeutic vaccines aimed to control the tumor growth and even to cure the patient. After an update of natural history of cervical HPV infection, the different target of vaccine strategies. The first published trials will be presented.

Objective: To give the preliminary results of a series of 37 operations for a para-aortic endoscopic curage by the extraperitoneal passage., Material and Methods: Thirty-seven patients, with an average age of 45.8 +/- 12 years, were operated on for cervical cancer, with an average tumor diameter of 4.9 +/- 1 cm. The indications were: the tumor's diameter > or = 4 cm (N = 24), one FIGO stage > or = IIb distal (N = 10), N+ pelvic (N = 3). The irradiation was pelvic (if N-) or abdominopelvic (if N+)., Results: The operation lasted 125.3 +/- 36.8 min, and the average number of ganglions removed was 21.2 +/- 10.2. The upper limit of the curage was submesenteric for nine patients and subrenal for 28. The immediate postoperatory complications were: a retroperitoneal hematoma, an acute intestinal occlusion treated by laparotomy, and a ureteral wound on a fixed ganglion, treated by an endoprosthesis. The number of N+ was ten in all, of which three were macroscopic: 0/1 for stage Ib1; 2/12 (16.7%) for Ib2; 4/14 (28.6%) for IIb proximal; 4/10 (40%) for IIb distal or more. There were 6/26 (23.1%) N+ microscopic cases for subrenal curages, versus 1/8 (12.5%) for submesenteric. (Excluding 3 N+ microscopic cases). All were given postoperatory radiotherapy except for one, who had a widened hysterectomy (N-). After an average follow-up of 9.5 +/- 5.9 months, there were two pelvic recurrences and six at a distance (of which four died). We had a lymphocele superinfection at six weeks on the diverticular sigmoiditis. There was an enteritis in a patient who had an abdominal irradiation after a laparotomy for acute occlusion., Conclusion: Out of 36 patients having postoperatory radiotherapy, para-aortic extraperitoneal curage diagnosed seven N+ microscopic cases, allowing 26 uniquely pelvic irradiations.

Objectives: From a review of 20 cases of primary carcinoma of the fallopian tube, we stress the various clinical aspects of the disease and discuss the possibilities of a preoperative diagnosis., Materials and Methods: A retrospective study covering the period between 1982 and 1996. An analysis of the different etiological factors mentioned in the literature, of the physical signs and symptoms of the carcinoma, of the patients' age and hormonal status as well as the role of additional investigations was conducted., Results: The average age of the patients was 62.3 years, 90% of the women had reached menopause and 15% were nullipara. A history of salpingitis was noted in 5% of the patients and another 5% had infertility problems. 20% of the patients had suffered from another carcinoma. Metrorrhagia was the most frequent clinical finding revealing the disease (55%) followed by abnormal secretions of blood stained liquid (15%). Hydrops Tubae Profluens was not observed in this series. The main complementary investigations performed were pelvic ultrasound scanning and hysterosalpingography, preoperative diagnosis was possible in 15% of cases; diagnosis was made during the operative procedure in 45% of cases and by pathologic examination in the remaining 40% of patients., Conclusion: Primary carcinoma of the fallopian tube is a rare form of cancer of unknown aetiology. Clinical signs are often unrelated and sometimes misleading; however, preoperative diagnosis is possible if one keeps in mind the existence of this carcinoma.