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Search for mutations of BRCA1 in women at hereditary risk for cancer is now possible. We asked the female gynaecologists of our county (north of France) their opinion about the search of a mutation of BRCA1 if they had a familial risk of breast cancer. Our aim was to obtain the opinion of informed women about their willingness to do the test for themselves and about the consequences they should accept. One hundred and eighty-three women received a questionnaire by post. The response rate was 56.3%. Twenty-four percent of the responders had a first degree relative with breast cancer. Most of the responders (87.4%; IC 95%: 81-93.8) would ask for the search of a mutation of BRCA1. The percentage of women who would accept the test is smaller for the women who have a first degree relative with breast cancer (72.0% vs 92.3%; P = 0.02). The reasons given to do the test were a better screening or prevention (69.7%) and the knowledge of a personal risk (49.4%). For breast cancer, 93.2% (95% CI: 88.4-98) would accept a screening protocol, 30.1% (CI: 21.3-38.9) would accept a prophylactic bilateral mastectomy. For ovarian cancer, 93.2% (CI: 88.4-98) would accept the screening, 52.4% (CI: 42.8-62) would accept a prophylactic ovariectomy. In conclusion, most of the informed women would ask for the test and the surgical options for reducing the risk of cancer are not absolutely rejected. Of course, only future studies will state precisely the choice of truly implicated women.

Objective: A retrospective study of local faiture and cosmetic results after conservative surgery for retroareolar breast cancer., Patients and Results: Seventy-seven patients underwent a conservative surgical procedure between 1983 and 1994. Median follow-up was 37,5 months. Fourteen patients experienced a recurrence (5 local, 2 local and distant, 7 distant). Only two probably interrelated factors were associated with a risk of local recurrence: nipple-areola complex removed or not, and pathological margins. Cosmetic results were evaluated with patient's questionnaires: 40/47 patients (85%) stated they were satisfied., Conclusion: In spite of the short follow-up, conservative surgery is a safe procedure for local control only in cases with negative margins. Procedure for nipple areola complex is now questionable. Cosmetic results are achieved if indication of central lumpectomy are confined to small and limited tumors. For other tumors, plastic remodelling is necessary.

During a period of 10 years, 91 ductal carcinomas in situ (DCIS) were operated. After a study of clinical and therapeutics characteristics, the evolution of the DCIS was studied. Eleven recurrences were seen in a period of 41 months. The actuarial risk of recurrence was 11% at 5 years and 17% at 8 years. About half of the recurrences were invasive and occurred 10 times out of 11 in the initial area or nearby. Among several factors studied, the association of radiotherapy with conservative surgery was the only one which reduced significantly the risk of recurrences.

The diagnosis of the lobular carcinoma in situ (LCIS), whose frequency is estimated to range from 0.8 to 3.8 p. cent of breast cancers on the whole, is exclusively anatomopathological since it does not have any specific clinical and/or radiological characteristics. After describing the two main differential diagnoses, the various possible treatments are studied, bearing in mind that the therapeutic strategy must take into account the three characteristics which are typical of LCIS: multicentricity, bilaterality and the possible occurrence of an invasive cancer.

221 patients have been operated for chronic pancreatitis, secondary to alcoholic intoxication in 92% of cases. Surgery was performed for a complication of the disease (69%), for intractable pain (30%), or for a false diagnostic of cancer; 265 operations were done, among which 41% of resections, 18.5% of internal derivations, and 14.3% of external derivations. Post-operative morbidity was 23.4% and hospital mortality was 6.4%. Late mortality was 35.5%, pancreatitis being responsible for more than half of those deaths during the first three post-operative years. Iterative surgery was necessary in 37 cases. The risk of diabetes was multiplied by 3.2 after resection. Results were good in 50% of cases after 5 years. An important factor was the arrest of alcoholic intoxication. There was no significant difference between resection and derivation. Internal drainage should be preferred when possible. Surgery must be reserved to grave or invalidating complications of chronic pancreatitis.

272 cancers of the thoracic esophagus were resected on 664 cases observed from 1975 to 1985 (resection rate: 41 p.c.): 8.1 p.c. were on the upper third, 71.3 p.c. on the middle third, 20.6 p.c. on the lower third of the esophagus. Tumors were classified as stage I (12: 4.5 p.c.), II (40: 15.2 p.c.), III (100: 37.9 p.c.), IV (112: 42.2 p.c.); 8 cases were not classified. Post-operative radiotherapy was administered to 90 patients. Hospital mortality was 50 (18.4 p.c.). Respiratory complications were the main lethal cause. After a post-operative survival of 81.6 p.c., survival at 1 year was 58.3 p.c., at 3 years 23.3 p.c., at 5 years 9.8 p.c. Actuarial survival at 5 years is 11.1 p.c. +/- 3, 17.2 p.c. for T1 and T2, 8 p.c. for T3. No advantage was noted comparing neck or intrathoracic anastomosis. Post-operative irradiation was beneficial. Factors influencing survival are staging, curative or no curative resection and post-operative irradiation for T3 N+. Nodes invasion is more important than invasion of the site of anastomosis. Palliative resections are the majority. They have no more severity than curative resections and give a 10 p.c. 5 years survival. The main effort must bear on a decrease of post-operative pulmonary complications and mortality.

Seventy-two cases of diffuse pulmonary contusion, 50 of which concerned multiple injury patients, are retrospectively described. The pleuro-parietal and associated lesions, the clinical, radiological and laboratory findings and the extent of the damage are analyzed. Treatment of shock (50 cases), mechanical ventilation (51 cases), thoracotomy (7 cases) and surgery of associated lesions are studied. Morbidity and mortality (34.7%) are detailed. The nosology of pulmonary contusion is discussed in relation to several factors, including shock, perfusions and associated lesions. The principles of treatment are restated. The most important complication is pulmonary superinfection. Diffuse pulmonary contusion is a serious condition. Associated lesions and their treatment contribute to its outcome.

Treatment of duodenal ulcer disease with an anti-acid preparation significantly reduces early postoperative complications after simple suture of a perforation, in relation to the course of the disease. Future prognosis of the latter is unpredictable even when those parameters, normally considered as being important, are allowed for. Percentage recovery is comparable with or without cimetidine. Treatment proposed is a two-stage operative procedure: 1) treat the peritonitis; 2) conduct recovery surgery at a later stage for recurrent lesions or those resistant to medical treatment. This therapy is based on the belief that emergency conditions do not require a complicated procedure and that the latter is useless in 45% of cases, which cannot be predetermined. This attitude is reinforced by the working conditions and the increased postoperative safety after simple suture as a result of the use of cimetidine.