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Diversi articoli dell⬢EMC illustrano le tecniche utilizzate nelle ricostruzioni, che esse siano immediate o differite. Questo articolo ha lo scopo di realizzare un collegamento tra questi diversi testi descrivendo le varie fasi che permettono di prendere una decisione con la paziente, cosi come gli argomenti che richiedono l⬢una o l⬢altra scelta. Il primo tempo consiste nel verificare la sicurezza oncologica delle tecniche che noi proponiamo, quindi nel conoscere bene la malattia e la paziente per determinare se la ricostruzione sia appropriata e secondo quali modalita.

En muchos articulos de la EMQ se describen las tecnicas utilizadas en las reconstrucciones, sean inmediatas o diferidas. El objetivo de este articulo es hacer de enlace entre estos diferentes textos, describiendo las diferentes etapas que permiten tomar una decision junto a la paciente, asi como los argumentos que justifican una u otra eleccion. La primera etapa consiste en verificar la seguridad oncologica de las tecnicas propuestas y, a continuacion, conocer la enfermedad y a la paciente para determinar si la reconstruccion es adecuada y segun que modalidades.

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 39 - N° 2 - p. 116-120

El tratamiento conservador del cancer de mama se considera tanto en terminos de resultados oncologicos como de preservacion de la imagen corporal. El objetivo de la cirugia oncoplastica es permitir la exeresis oncologica y aprovechar el tejido restante para obtener el mejor resultado posible, que puede llevarse a cabo con cirugia solo en la mama enferma o mediante una operacion bilateral. Las lesiones pequenas y medianas pueden tratarse con cirugia unilateral, respetando algunas reglas de la oncoplastia. Para evitar las deformaciones, tras las resecciones amplias es necesario aplicar los principios de la cirugia plastica en ambas mamas. La finalidad de este articulo es presentar los principios y las tecnicas, ya se trate de una intervencion quirurgica uni o bilateral.

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.

Background Based on clinical observations and previous animal studies, laparoscopic surgery for malignant disease is regarded as controversial. We used a rat model to measure and compare the tumor growth, proliferation, and dissemination of a microscopic peritoneal carcinomatosis after CO2 intraperitoneal insufflation or laparotomy.

Standards, Options et Recommandations pour la radiotherapie des patientes atteintes de cancer de l'endometre. Contexte. - La Federation nationale des centres de lutte contre le cancer (FNCLCC) et les Centres regionaux de lutte contre le cancer (CRLCC), en collaboration avec des partenaires des secteurs public (CHU, CHG), prive et certaines societes savantes ont entrepris depuis 1993 d'elaborer des recommandations pour la pratique clinique en cancerologie: les « Standards, Options et Recommandations » (SOR). L'objectif de l'operation SOR est d'ameliorer la qualite et l'efficience des soins aux patients atteints de cancer en fournissant aux praticiens une aide a la decision facilement utilisable. La methodologie d'elaboration des SOR repose sur une revue et une analyse critique des donnees de la litterature scientifique par un groupe d'experts pluridisciplinaire, permettant de definir, sur la base du niveau de preuve scientifique et du jugement argumente des experts, des « Standards », des « Options » et des « Recommandations », Avant publication, les SOR sont revus par des experts independants. Objectifs. - Definir, sur la base d'une revue de la litterature et de l'accord d'experts, des Standards, Options et Recommandations pour la radiotherapie des patientes atteintes de cancer. Methodes. - Un groupe de travail multidisciplinaire mis en place par la Federation nationale des centres de lutte contre le cancer (FNCLCC) a revu les donnees scientifiques disponibles concernant la radiotherapie du cancer de l'endometre. Apres selection des articles, synthese des resultats et redaction des SOR, le document a ete soumis pour relecture et approbation a des relecteurs independants et aux 20 comites techniques et medicaux des CRLCC. Resultats. - Les principales recommandations sont 1) pour les tumeurs de stade IA la surveillance est le traitement complementaire standard. Pour les tumeurs de stade IB (grade 1 ou 2), une curietherapie vaginale ou une surveillance sans traitement complementaire peuvent etre envisagees. Pour les tumeurs de stade IB (grade 3), et de stade IC, deux trailements complementaires sont possibles: une radiotherapie externe pelvienne avec une curietherapie de surimpression ou une curietherapie vaginale. 2) Le traitement des stades II peut etre preoperatoire lorsque l'atteinte du col est prouvee par un curetage ou une biopsie de l'endocol positifs. Pour les tumeurs de stade IIA apres chirurgie premiere, une curietherapie vaginale est realisee si la penetration du myometre est < 50 % ou si la tumeur est de grade 1 ou 2. En cas de penetration plus profonde ou de grade plus eleve, et pour les stades IIB, une radiotherapie externe avec curietherapie vaginale de surimpression systematique doit etre realisee. 3) Le traitement complementaire des stades IIA apres chirurgie est une radiotherapie externe soit pelvienne, soit abdominopelvienne. Dans certains cas, le traitement medical peut-etre une option. Pour les tumeurs de stade IIIB, une radiotherapie externe postoperatoire avec curietherapie doit etre realisee. Pour les tumeurs de stade IIIC, le traitement standard est une radiotherapie externe (pelvienne ou pelvienne et lomboaortique) avec eventuellement une curietherapie de surimpression (standard). En cas d'atteinte des sites extra-uterins, une irradiation abdomino-pelvienne est recommandee. 4) Les patientes inoperables doivent etre traitees par radiotherapie externe et curietherapie pour les tumeurs de stade I et II. Pour les malades inoperables du fait de leur tumeur, le traitement est le plus souvent symptomatique, associant irradiation externe et traitement medical.

The aim of this inquiry was to question 50 patients before a traditional hospitalization in a regional center, in order to know their opinion about one-day surgery. Among 44 answers from 41 women and 3 men, 29 were against, 11 favourable and 4 without opinion. After their hospitalization, only 4 changed their mind. The main reasons, in case of unfavourable answer, were lack of security and fear of pain. Psychologic aid in traditional hospitalization is frequently cited (34%). This has to be taken into account in ambulatory cases.

Resume Contexte La Federation nationale des centres de lutte contre le cancer (FNCLCC) et les Centres regionaux de lutte contre le cancer (CRLCC), en collaboration avec des partenaires des secteurs public (CHU, CHG), prive et les societes savantes ont entrepris depuis 1993 d'elaborer des recommandations pour la pratique clinique en cancerologie: les ≪Standards, Options et Recommandations≫ (SOR). L'objectif de l'operation SOR est d'ameliorer la qualite et l'efficience des soins aux patients atteints de cancer en fournissant aux praticiens une aide a la decision facilement utilisable. La methodologie d'elaboration des SOR repose sur une revue et une analyse critique des donnees de la litterature scientifique par un groupe d'experts pluridisciplinaire, permettant de definir, sur la base du niveau de preuve scientifique et du jugement argumente des experts, des ≪ Standards ≫, des ≪ Options ≫ et des ≪ Recommandations ≫. Avant publication, les SOR sont revus par des experts independants. Objectifs Mettre a jour, en adequation avec la methodologie d'elaboration des SOR, des Standards, des Options et des Recommandations pour la prise en charge des patientes atteintes de cancer du col, et en particulier la place de la radiochimiotherapie concomitante. Methodes Une recherche bibliographique a ete effectuee en utilisant Medline ® (jusqu'en avril 1999), Cancerlit ® , Embase ® et Toxline ® . Apres selection des articles, synthese des resultats et redaction des SOR, le document a ete soumis pour relecture et approbation a des relecteurs independants et aux 20 comites techniques et medicaux des CRLCC. Resultats Les principales recommandations concernant la place de la radiochimiotherapie des cancers du col sont 1/Il n'y a pas d'indication a une chimiotherapie concomitante a la radiotherapie en cas de tumeur de stades IB1, IIA, IIB proximaux de bon pronostic. Les donnees disponibles montrent une amelioration significative du controle local (niveau de preuve A) et de la survie globale (niveau de preuve B1) par la radiochimiotherapie concomitante par rapport a la radiotherapie seule ou l'association radiotherapie-hydroxyuree. Pour les stades IB, IIA a MB proximaux ayant des facteurs de mauvais pronostic (taille tumorale superieure a quatre centimetres et/ou envahissement ganglionnaire pelvien et/ou envahissement microscopique des parametres) sans envahissement ganglionnaire lomboaortique, la radiochimiotherapie concomitante peut etre consideree comme un standard. Ce benefice semble moins net pour les stades IIB distaux, III et IVA sans envahissement lomboaortique (niveau de preuve C) et doit etre confirme (accord d'experts), 2/La toxicite de la radiochimiotherapie est essentiellement hematologique et digestive (niveau de preuve B1). Elle est superieure a celle de la radiotherapie seule (niveau de preuve B1). 3/Ces resultats ont ete obtenus le plus souvent par l'association d'une chimiotherapie a base de cisplatine, utilise seul ou associe au 5-FU. A efficacites tumorales equivalentes, la toxicite de l'association cisplatine, 5-FU, hydroxyuree etait superieure a celle du cisplatine seul dans un essai ayant compare ces deux protocoles. Un benefice en termes de survie a ete egalement obtenu avec l'association d'une radiochimiotherapie concomitante et d'une chimiotherapie adjuvante utilisant l'epirubicine (une seule etude, niveau de preuve C). Ces resultats necessitent d'etre confirmes. 4/ Les modalites exactes d'administration de la chimiotherapie n'ont pas ete clairement etablies. En effet, dans ces essais, certains schemas utilisaient le cisplatine hebdomadaire a une posologie de 40 mg/m 2 et d'autres, toutes les trois a quatre semaines, a des doses variant de 50 mg/m 2 a 75 mg/m 2 par cycle. De nouvelles etudes randomisees permettront vraisemblablement d'etablir les schemas optimaux de chimiotherapie en association a la radiotherapie externe et a la curietherapie.

The authors report one case of port site recurrence 5 months after thoracoscopic resection of a pulmonary metastasis in a 68-year-old woman.

From March 2003 to April 2004, were prospectively collected in France 1,289 ductal carcinoma in situ (DCIS) with data on diagnosis, patient and tumour characteristics, and treatments. Median age was 56 years (range, 30-84). DCIS was diagnosed by mammography in 87.6% of patients. Mastectomy (M), conservative surgery alone (CS) and conservative surgery with radiotherapy (CS + RT) were performed in 30.5, 7.8 and 61.7% of patients, respectively. Sentinel node biopsy (SNB) and axillary dissection (AD) were performed in 21.3 and 10.4% of patients, respectively. Hormone therapy was administered to 13.4% of the patients. Nuclear grade was low in 21% of patients, intermediate in 38.5% and high in 40.5%. Excision was considered complete in 92% (CS) and 88.3% (CS + RT) of patients. Treatment modalities varied widely according to region: mastectomy rate, 20-37%; adjuvant RT, 84-96%; hormone treatment, 6-34%. Our survey on current DCIS management in France has highlighted correlations between pathological features (tumour size, margin, grade) and treatment options, with several similar variations to those observed in recent UK and US studies.

Description of four cases of anaphylactic shock with blue dye injection (bleu patenté V Guerbet 2.5%) during sentinel node biopsy for breast cancer.Women with breast carcinoma and combined approach with radioactive tracer and blue patent injection.Four cases were observed, which means an incidence of 0.57%. We report one case of grade II anaphylactic reaction and three cases of grade III requiring active reanimation and adrenaline perfusion. One patient developed a pulmonary embolism during the postoperative period, but no death was observed.We find an incidence of 1.06% of allergy but only 0.25% of anaphylactic shock (grade III). These rare but serious cases must weigh up the benefits and risks of using blue dye. We suggest using blue dye injection only in case of radioisotope detection failure. Of course, this approach must be evaluated.

Tamoxifen has been used for two decades as adjuvant therapy for breast cancer. It is also now being used to try and prevent this disease in women at high risk. A series of 89 patients who developed endometrial cancer on adjuvant has been identified from nine French cancer institutes. Although there was a high frequency of superficial, generally well-differentiated forms, some patients did have aggressive disease with a relatively poor outcome and there were 10 deaths from endometrial carcinoma. These data support gynaecological surveillance of women receiving tamoxifen therapy.

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.

The aim of this study was to evaluate whether 99m Tc-MIBI scintimammography can improve the diagnostic value of mammography for the differentiation of benign and malignant breast microcalcifications. In 41 women presenting 45 clusters of microcalcifications, a 99m Tc-MIBI scintimammography was performed before open biopsy. There were 24 malignant lesions (53%). The sensitivity (SE) and specificity (SP) of 99m Tc-MIBI scintimammography were 58.3% and 81%, and the positive and negative predictive values (PPV, NPV) were 78% and 63%, respectively. SE and PPV increased for lesions over 10mm and for the younger patients (under 50 years). No correlation was found between true positive uptake and breast cancer invasiveness: 69% (9/13) for invasive lesions and 45% (5/11) for noninvasive lesions ( p =0.48). 99m Tc-MIBI scintimammography was more often positive in high grade than in low- or intermediate-grade ductal carcinoma in situ ( p =0.03). The results were analysed according to the morphologic aspect of the microcalcifications. 99m Tc-MIBI scintimammography could not be used for routine evaluation of all the microcalcifications detected by mammography.

The aim of this work was to demonstration the relations between CO(2) laparotomy and peritoneal carcinosis. The first part of this review presents published observations of disseminated peritoneal carcinosis after laparoscopy with CO(2) insufflation. The second part deals with the possible effects of CO(2) laparoscopy on the mechanism of carcinosis.We made a Medline search for cases of peritoneal dissemination after CO(2) laparoscopy. We present here the published results as well as data from comparative studies conducted in humans and animals on the effects of each step of CO(2) laparoscopy on carcinogenesis and the progress of carcinosis.Most of the published cases on peritoneal dissemination after CO(2) laparoscopy concerned management of ovarian carcinomas where malignancy was not diagnosed before the operation and not treated immediately with laparotomy. The significance of peritoneal dissemination appears to be related to the delay between laparoscopy and laparotomy. No comparative study in humans has been published. For animal studies, it has been difficult to design valid animal modes. Those we present show that laparoscopy has no negative influence on tumor growth but that it may affect peritoneal dissemination. Laparoscopy can participate in diffusion of tumor cells either due to repeated manipulation with contaminated instruments or because of the insufflation itself. These cells can be seeded on traumatized areas of the peritoneum or parietal wall or on the port tracts. The recent work by Volz has proven the effect of CO(2) which can cause a change in the ultra-structure of the peritoneum. This may facilitate peritoneal seeding of the malignant cells. No other study has shown any evidence of increased intraperitoneal tumor growth. Only primary results of post-laparoscopy liver metastasis have diverged. Laparoscopy does not seem to have a negative effect on general immunity, but possible changes in intraperitoneal immunity remain to be elucidated.Observations concerning peritoneal dissemination are found in cases where CO(2) insufflation was used for laparoscopy, but no studies have proven certain risk greater for laparoscopy than for laparotomy. Maximum precautions must be taken during the management of suspicious ovarian lesions.

To develop clinical practice guidelines according to the definitions of the Standards, Options and Recommendations project for the radiotherapy of carcinoma of the endometrium.Data were identified by searching Medline and personal reference lists of members of the expert groups. Once the guidelines were defined, the document was submitted for review to independent reviewers, and to the medical committees of the 20 French Cancer Centres.The main recommendations for the radiotherapy of carcinoma of the endometrium are: 1) For grade 1 and 2 stage IA tumours, follow-up alone is standard as additional treatment. For grade 1 and 2 stage IB tumours, vaginal brachytherapy or follow-up alone are options. For grade 3, stage IB tumours and stage IC disease, there are two treatment options: external pelvic radiotherapy with a brachytherapy boost or vaginal brachytherapy. 2) Treatment for stage II disease can be preoperative when stage II disease has been suggested by a positive endometrial curettage. Postoperative vaginal brachytherapy is given for stage IIA tumours if the penetration of the myometrium is less than 50% or if the tumour is grade 1 or 2. In the case of deep penetration, or higher grade disease, or for stage IIB external radiotherapy with brachytherapy boosting must be undertaken routinely. 3) After surgery, for stage IIIA disease, either external pelvic radiotherapy or abdomino-pelvic radiotherapy is indicated, along with medical treatment in certain patients. For stage IIIB tumours, postoperative external radiotherapy with brachytherapy (if possible) should be undertaken. For stage IIIC tumours, standard treatment is external (pelvic or pelvic and para-aortic) radiotherapy followed or not by a brachytherapy boost. In case of extrauterine sites involved abdomino-pelvic irradiation is recommended. 4) Standard treatment for inoperable stage I and II disease is external radiotherapy and brachytherapy. For patients with inoperable stage III or IV disease, treatment is often symptomatic, combining external radiotherapy and medical treatment.

1Centre Leon Berard, Lyon; 2FNCLCC, Paris; 3Institut Bergonie, Bordeaux; 4Centre Jean Perrin, Clermont-Ferrand; 5Centre Paul Papin, Angers; 6CHU Bretonneau, Tours; 7Centre Alexis Vautrin, Nancy; 8Centre Henri Becquerel, Rouen; 9CHU, Angers; 10CHU, Hopital Arnaud de Villeneuve, Montpellier; 11Centre Paul Strauss, Strasbourg; 12Clinique Sainte-Catherine, Avignon, France British Journal of Cancer (2001) 84(Supplement 2), 31–36 © 2001 FNCLCC doi: 10.1054/ bjoc.2001.1760, available online at http://www.idealibrary.com on

The "Standards, Options and Recommendations" (SOR) project, started in 1993, is a collaboration between the Federation of the French Cancer Centres (FNCLCC), the 20 French Cancer Centres and specialists from French Public Universities, General Hospitals and Private Clinics. The main objective is the development of clinical practice guidelines to improve the quality of health care and outcome for cancer patients. The methodology is based on literature review and critical appraisal by a multidisciplinary group of experts, with feedback from specialists in cancer care delivery.To develop clinical practice guidelines according to the definitions of the Standards, Options and Recommendations project for the surgical management of carcinoma of the endometrium.Data were identified by searching Medline and personal reference lists of members of the expert groups. Once the guidelines were defined, the document was submitted for review to independent reviewers, and to the medical committees of the 20 French Cancer Centres.The main recommendations for the surgical management of carcinoma of the endometrium are: 1) where-ever possible, surgery is the primary treatment of both localised and advanced disease; 2) surgery is performed according to the stage of the cancer and the status of the patient; 3) surgery for stages I and II disease entails total abdominal hysterectomy and bilateral salpingo-oophorectomy. A modified radical hysterectomy is undertaken in cases of macroscopic cervical involvement. An omenectomy is recommended for serous papillary types. Pelvic lymphadenectomy for the purposes of precise staging is undertaken if the patient is of good performance status and without bad pronostic factors. Para-aortic lymphadenectomy can be undertaken to determine involvement of para-aortic nodes; 4) surgery for stages III and IV: radical surgery must be undertaken if at all possible with additional treatment as indicated. In the case of advanced disease, debulking surgery is indicated.

The aim of this inquiry was to question 50 patients before a traditional hospitalization in a regional center, in order to know their opinion about one-day surgery. Among 44 answers from 41 women and 3 men, 29 were against, 11 favourable and 4 without opinion. After their hospitalization, only 4 changed their mind. The main reasons, in case of unfavourable answer, were lack of security and fear of pain. Psychologic aid in traditional hospitalization is frequently cited (34%). This has to be taken into account in ambulatory cases.

The "Standards, Options and Recommendations" (SOR) project, started in 1993, is a collaboration between the National Federation of the French Cancer Centres (FNCLCC), the 20 French Cancer Centres (CRLCC) and specialists from French public universities, general hospitals and private clinics. The main objective is the development of clinical practice guidelines to improve the quality of health care and outcome for cancer patients. The methodology is based on literature review and critical appraisal by a multidisciplinary group of experts, with feedback from specialists in cancer care delivery.To update, according to the methodology of SOR, the Standards, Options and Recommendations for the management of patients with cancer of the cervix, and in particular, the place of concomitant radiochemotherapy.Data have been identified by a literature search using Medline (to April 1999) and the personal reference lists of experts. Once the guidelines were defined, the document was submitted for review to independent national and international reviewers and to the medical committees of the CRCC.The principle recommendations concerning the place of radiochemotherapy in the treatment of cancer of the cervix are 1/ the available data shows a significant increase in local control (level of evidence A) and of overall survival (level of evidence B1) following concomitant radiochemotherapy as compared to radiotherapy alone or the combination of radiotherapy-hydroxyurea. For stages IB, IIA, proximal IIB with bad prognostic factors (tumour size greater than 4 cm and/or invasion of pelvic nodes and/or microscopic invasion of the parametrium) and without lumbo-aortic nodal invasion, concomitant radiochemotherapy can be considered as standard treatment. This benefit is less clear for stages distal IIB, III and IVA without para-aortic nodal invasion (level of evidence C) and must be confirmed (expert agreement). 2/ the toxicity of radiochemotherapy is essentially haematologic and gastrointestinal (level of evidence B1) and is greater than that of radiotherapy alone (level of evidence B1). 3/ these results have been obtained by the combination of chemotherapy based oncisplatin alone, or in combination with 5-FU. Although of equal benefit, the toxicity of the cisplatin/5-FU/ hydroxyurea combination was greater than that of cisplatin alone in a trial comparing the two protocols. A significantly longer survival have also been obtained by the combination of chemoradiation and adjuvant chemotherapy with epirubicin (level of evidence C). These results must be confirmed. 4/ the exact means of delivering the chemotherapy has not been clearly established. In fact, in these trials, some protocols use cisplatin weekly at a dose of 40 mg/m2 and others every three or four weeks at doses ranging from 50 to 75 mg/m2. Subsequent randomised studies are likely to establish optimal schema for the delivery of chemotherapy when combined with external radiotherapy and brachytherapy.

Based on clinical observations and previous animal studies, laparoscopic surgery for malignant disease is regarded as controversial. We used a rat model to measure and compare the tumor growth, proliferation, and dissemination of a microscopic peritoneal carcinomatosis after CO(2) intraperitoneal insufflation or laparotomy.Peritoneal carcinomatosis was induced in three groups of 27 BD IX rats each with intraperitoneal injections of 106 DHD/K12 cells, an aneuploid tumor cell line. At 48 h after tumor cell injection, the animals were randomly divided into three groups to undergo different types of intervention. All animals were anesthetized for 20 min (Halothane). The control group had no surgical intervention (group C), group I had CO(2) insufflation (7 mmHg),and group L had a midline laparotomy (5-cm). Neither bowel manipulation nor any other traumatic action was performed. Two weeks later, the rats were killed and the incidence, type, and dissemination of carcinomatosis were evaluated. We also measured the tumor's weight. Malignant omentum was sampled for flow cytometry analysis (DNA ploidy, S-phase fraction).The incidence of carcinomatosis did not differ among the groups. The mean score of macroscopic characteristics of the carcinomatosis was 2.8 +/- 1.9 in group L, 2.9 +/- 1.9 in group I, and 3 +/- 1.9 in group C (NS). The location of the implants did not differ, except for parietal peritoneum location, which was more frequent in group L (p0.01). The tumor weight was 4.96 g +/- 3.2 in group L, 5.55 g +/- 3.2 in group C, and 5.75 g +/- 3.4 in group I (NS). The percentage of aneuploid cells and S-phase fraction did not differ statistically among the groups.These results indicate that CO(2) insufflation does not cause more effects than laparotomy when tumors cells are present before the beginning of the surgery. Further studies are needed to determine the influence of other steps in laparoscopic surgery on tumor growth and dissemination.

The prognosis for patients with ovarian serous borderline tumors is generally considered to be excellent. It is worse for women with an advanced stage, especially when invasive peritoneal implants are present. There is no general agreement regarding standard treatment in such cases. To clarify the significance of this invasive peritoneal proliferation and to devise a rational treatment approach, we review the available series. From this review of literature, it appears necessary to emphasize the importance of an initial adequate peritoneal staging of all ovarian tumors. After a complete removal of the lesions, the question of adjuvant therapy must be discussed.

The "Standards, Options and Recommendations" (SOR) project, started in 1993, is a collaboration between the National Federation of the French Cancer Centres (FNCLCC), the 20 French Cancer Centres (CRLCC) and specialists from French public universities, general hospitals and private clinics. The main objective is the development of clinical practice guidelines to improve the quality of health care and outcome for cancer patients. The methodology is based on literature review and critical appraisal by a multidisciplinary group of experts, with feedback from specialists in cancer care delivery.To update, according to the methodology of SOR, the Standards, Options and Recommendations for the management of patients with cancer of the cervix, and in particular, the place of concomitant radiochemotherapy.Data have been identified by a literature search using Medline (to April 1999) and the personal reference lists of experts. Once the guidelines were defined, the document was submitted for review to independent national and international reviewers and to the medical committees of the CRLCC.The principle recommendations concerning the place of radiochemotherapy in the treatment of cancer of the cervix are: 1) the available data shows a significant increase in local control (level of evidence A) and of overall survival (level of evidence B1) following concomitant radiochemotherapy as compared to radiotherapy alone or the combination of radiotherapy-hydroxyurea. For stages IB, IIA, proximal IIB with bad prognostic factors (tumour size greater than 4 cm and/or invasion of pelvic nodes and/or microscopic invasion of the parametrium) and without lumbo-aortic nodal invasion, concomitant radiochemotherapy can be considered as standard treatment. This benefit is less clear for stages distal IIB, III et IVA without para-aortic nodal invasion (level of evidence C) and must be confirmed (expert agreement); 2) the toxicity of radiochemotherapy is essentially haematologic and gastrointestinal (level of evidence B1) and is greater than that of radiotherapy alone (level of evidence B1); 3) these results have been obtained by the combination of chemotherapy based on cisplatin alone, or in combination with 5FU. Although of equal benefit, the toxicity of the cisplatin/5FU/hydroxyurea combination was greater than that of cisplatin alone in a trial comparing the two protocols. A significantly longer survival have also been obtained by the combination of chemoradiation and adjuvant chemotherapy with epirubicin (level of evidence C). These results must be confirmed; 4) the exact means of delivering the chemotherapy has not been clearly established. In fact, in these trials, some protocols use cisplatin weekly at a dose of 40 mg/m2 and others every three or four weeks at doses ranging from 50 to 75 mg/m2. Subsequent randomised studies are likely to establish optimal schema for the delivery of chemotherapy when combined with external radiotherapy and brachytherapy.

A case of an inflammatory breast metastasis from ovarian carcinoma is reported. Recognition of this inflammatory lesion as being metastatic is useful in avoiding inadequate treatment.

Linitis plastica of the stomach was diagnosed in four patients. Endoscopic ultrasonography (EUS) was performed in four cases; they were monitored by EUS and had their treatment adapted accordingly, According to the present study, the typical criteria of gastric linitis at EUS are: (a) rigidity of the gastric wall; (b) a wall thickness exceeding 6 mm; (c) a second enlarged layer marginally more echogenic than the fourth hypoechogenic layer (muscularis propria); (d) a third hyperechogenic enlarged layer; and (e) a poor demarcation between layers. Gastric linitis appears more likely to be specific metastasis from lobular breast carcinoma. In most of the follow-up cases, EUS showed correlation with a subsequent decrease of the CA15.3 level. At present, EUS seems to be the most effective and least invasive examination for clinical diagnosis and treatment surveillance of secondary gastric linitis arising from infiltrating lobular carcinoma (ILC) of the breast.

The authors report one case of port site recurrence 5 months after thoracoscopic resection of a pulmonary metastasis in a 68-year-old woman.

Ovarian cancer is the most common cause of gynecologic cancer death, as most patients present with advanced disease, in which the prognosis is poor. Five year-survival is only 35% for all stages, while it exceeds 90% in stage I. Consequently, there has been heightened interest in the development of screening modalities that can detect ovarian cancer at an early stage to reduce the mortality of this disease. Unfortunately, transvaginal sonography and color Doppler imaging still have a high false positive rate and low specificity increasing the number of surgical procedures, even among women with a strong family history of ovarian cancer. Psychological impact and economical cost has also to be discussed when considering such programs.

Five studies comparing metastatic patterns of lobular and ductal carcinoma have reported conflicting results. These results are based on the evaluation of heterogeneous groups, without taking clinical differences into account. The aim of this clinical study is to compare metastatic patterns of matched ductal and lobular carcinomas. One hundred eighty-eight lobular carcinomas were matched with 188 ductal carcinomas who showed identical ages, menopausal status, TNM, and dates of treatment. Hepatic, lung and brain metastases are more frequent in ductal carcinoma. Metastases to the gastrointestinal system, gynecologic organs, and peritoneum are more characteristic of lobular carcinoma. Life table analysis of overall and disease free survival shows no significant differences. The metastatic patterns of ductal and lobular carcinomas are different, and physicians should be aware that the classical staging of the breast cancer is not fit to lobular carcinoma. fit to lobular carcinoma. Could we define patients presenting high metastatic risks? Could we use CA. 125, sonography, laparoscopy in the staging? Should we change the whole therapeutic approach of lobular carcinoma?

Since tamoxifen is widely used in breast cancer treatment and has been proposed for the prevention of breast cancer, its endometrial iatrogenic effects must be carefully examined. We have investigated the association between endometrial cancer and tamoxifen use or other treatments in women treated for breast cancer in a case-control study. Cases of endometrial cancer diagnosed after breast cancer (n = 135) and 467 controls matched for age, year of diagnosis of breast cancer and hospital and survival time with an intact uterus were included. Women who had received tamoxifen were significantly more likely to have endometrial cancer diagnosed than those who had not (crude relative risk = 4.9, p = 0.0001). Univariate and adjusted analyses showed that the risk increased with the length of treatment (p = 0.0001) or the cumulative dose of tamoxifen received (p = 0.0001), irrespective of the daily dose. Women who had undergone pelvic radiotherapy also had a higher risk (crude relative risk = 7.8, p = 0.0001). After adjusting for confounding factors, the risk was higher for tamoxifen users (p = 0.0012), treatment for more than 3 years (all p0.03) and pelvic radiotherapy (p = 0.012). Women who had endometrial cancer and had received tamoxifen had more advanced disease and poorer prognosis than those with endometrial cancer who had not received this treatment. Our results suggest a causal role of tamoxifen in endometrial cancer, particularly when used as currently proposed for breast cancer prevention. Pelvic radiotherapy may be an additional iatrogenic factor for women with breast cancer. Endometrial cancers diagnosed in women treated with tamoxifen have poorer prognosis. Women who receive tamoxifen for breast cancer should be offered gynaecological surveillance during and after treatment. A long-term evaluation of the risk-benefit ratio of tamoxifen as a preventive treatment for breast cancer is clearly warranted.

Eight patients with intestinal metastases from breast cancer are described. The different clinical presentations and pathological types are studied. The difficulty in distinguishing such uncommon secondary sites of breast cancer from primary intestinal cancer is emphasized. Attention should be paid to intestinal symptoms in women with a history of infiltrating lobular breast cancer: in agreement with recent literature data the lobular type seems mainly responsible for gastrointestinal and peritoneal involvement originating from breast cancer (7 cases out of 8 in our series). Prolonged survival could be obtained if no metastases elsewhere were found with appropriate treatment including ablative surgery, chemotherapy and hormonotherapy.

The results of pelvic and para-aortic lymphadenectomy performed in 24 patients with primary ovarian cancer are reported. The lymph node invasion rate was 20 percent in stages where the disease was apparently limited to the pelvis, and 73 percent in more advanced stages. Invasion was as frequently found at postoperative second-look laparotomy (54 percent) as at initial exploratory laparotomy (46 percent). Retroperitoneal expansion equally involved the pelvic and para-aortic lymph nodes: among 12 patients with positive lymphadenectomy, 8 had combined pelvic and para-aortic invasion, 2 had exclusively pelvic invasion and 2 had exclusively para-aortic invasion. We would therefore recommend to perform lymphadenectomy during the first operation, particularly in presumed stage I or II cancer, and to dissect the lymph nodes in both the pelvic cavity and the lumbo-aortic region.

The authors report about the intraoperative discovery of a metastatic thrombus in the common bile duct, produced by a right renal adenocarcinoma metastasized in the Vth segment of the liver. As far as the treatment is concerned, in addition to nephrectomy, the use of a simple device allowed intraluminal irradiation with radioiridium. Although this approach is palliative, it resulted from the desire to maintain the patency of the common bile duct by controlling tumor proliferation within the duct. The pathogenesis of this proliferation is discussed. In our opinion, the favorable outcome after 18 months confirms the merits of this therapeutic attitude, which can be used for such tumoral extensions.

The authors report two cases of Demons-Meigs' syndrome, one following an ovarian fibrothecoma and the other an ovarian fibroma. There was a striking rise in the serum CA 125 level which was higher than 200 UI/ml, suggestive of cancer of the ovary in both cases. With the help of the literature data, the clinicopathological features of this rare condition and the different hypotheses concerning its aetiology are commented.

The authors report a retrospective clinicopathologic study of 8 cases of uterine metastases from breast cancer. This is the largest surgical series dealing with this subject to be published to date. Not autopsy case has been considered. Much information has come out of this analysis and out of the international literature review: secondary location in the uterus can occur many years after the diagnosis and treatment of primary cancer of the breast; infiltration of the endometrium appears as common as infiltration of the myometrium; the histological type is nearly always invasive lobular carcinoma. The later was found in seven out of eight cases; the evaluation of hormone receptor levels in the surgical specimens has shown that most breast cancers metastasizing to the uterus are hormone-dependent.

The authors report a case of spontaneous rupture of the liver during pregnancy which occurred in a 31-year old multiparous woman with pre-eclampsia. In the literature, this rare event is associated with both maternal and fetal high mortality rates. Histopathological studies have shown periportal parenchymal lesions, larger sinusoidal fibrin deposits and hemorrhagic infarctions. Our case was successfully managed with termination of pregnancy by cesarean section without surgical procedure toward subcapsular hematoma. Long term follow-up using liver scans is needed.