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Resume Objectif Demontrer la faisabilite de l’hysterectomie par voie cœlioscopique en ambulatoire en France par l’evaluation de la qualite de vie postoperatoire. Methodes Nous avons mene une etude prospective randomisee monocentrique en France entre 2013 et 2016 incluant 42 patientes devant beneficier d’une hysterectomie par voie cœlioscopique. Le critere de jugement principal etait l’evaluation de la qualite de vie postoperatoire a l’aide du questionnaire standardise Euroquol la veille de l’intervention puis au 3e et au 30e jour postoperatoire. Les criteres de jugement secondaires etaient l’evaluation de la douleur postoperatoire, la qualite de vie globale, la consommation d’antalgiques et l’anxiete. Les patientes ont ete randomisees en deux groupe, le groupe A avec un sejour d’hospitalisation conventionnel de 2 a 3 jours et le groupe B avec un sejour court, la sortie se faisant le lendemain de l’intervention. Resultats Vingt et un patientes ont ete randomisees dans le groupe A ainsi que dans le groupe B. Nous n’avons pas releve des differences significatives entre les deux groupes de notre etude que ce soit sur notre critere de jugement principal ou nos criteres d’evaluations secondaires. A J3, la moyenne du score Euroquol etait de 0.68 pour le groupe A contre 0,50 pour le groupe B (p = 0,05). De meme, les moyennes des scores portant sur la douleur postoperatoire etaient comparables a hauteur de 70,6 dans le groupe A et 61,8 dans le groupe B (p = 0,21). La tendance etait a l’identique concernant le score de qualite de vie ou l’anxiete. Conclusion La realisation de l’hysterectomie cœlioscopique en ambulatoire parait faisable au vu de notre etude.

Resumen Las lesiones intraepiteliales del cuello uterino tienen relacion con el virus del papiloma humano (VPH) y actualmente, por ejemplo en Francia, se detectan mediante frotis cervicouterino (en espera de la puesta en marcha de la deteccion precoz virologica organizada). Se distinguen las lesiones escamosas de bajo grado, que no se consideran lesiones premalignas pero en las que predominan los VPH de alto riesgo, lo cual justifica un seguimiento, de las lesiones de alto riesgo escamosas, que tienen riesgo de degeneracion maligna y requieren un tratamiento y vigilancia. Las recomendaciones francesas precisan las indicaciones terapeuticas, que privilegian, en caso de lesion de bajo grado, una vigilancia y, en caso de lesion de alto grado, un tratamiento (o bien destruccion en las lesiones menos graves, poco amplias y claramente identificadas, o bien, con mayor frecuencia, exeresis con control colposcopico [para preservar al maximo el cuello], que permite un analisis exhaustivo de estas lesiones). Actualmente, el pilar de la vigilancia de estas lesiones es la prueba del VPH, que por regla general se realiza inicialmente 6 meses despues del tratamiento y se propone despues a largo plazo. Aparte, estan las lesiones de adenocarcinoma in situ, mas raras, de deteccion y diagnostico mas dificiles, cuyo tratamiento es la histerectomia, con la opcion, en las pacientes con un proyecto de embarazo, de tratamiento de exeresis con la condicion de retirar todas las lesiones y de aceptar el principio de una vigilancia prolongada.

Title: Impact of Lymphadenectomy on Survival of Patients with Serous Advanced Ovarian Cancer After Neoadjuvant Chemotherapy: A French National Multicenter Study (FRANCOGYN). Introduction/Background* The population of interest to this study comprised individuals with advanced-stage ovarian carcinoma who were exposed to neoadjuvant chemotherapy (NAC) followed by interval debulking surgery (IDS). Those who had not received systematic lymphadenectomy (SL; Group 1) were compared to those who had received SL (Group 2). Outcome measures included progression-free survival (PFS), overall survival (OS), and surgical complications. (Group 1). Methodology This was a retrospective, multicenter cohort study in nine referral centers of France between January 2000 and June 2017. OS analysis using the multivariate Cox regression model was performed. PFS and surgery-related morbidity were analyzed. Result(s)* Of the 255 patients included, 100 were in Group 1 and 155 in Group 2. Patient majority was, on average, younger and less comorbid, with predominant R0 surgery in Group 2. Dindo–Clavien score was similar between the two groups (p = 0.15). Median OS was 26.8 months in Group 2 and 27.6 months in Group 1. SL was not statistically significant on OS (p = 0.7). Median PFS was 18.3 months in Group 2 and 16.6 months in Group 1. SL had positive impact on PFS (p = 0.005). Conclusion* Patients who had received SL (Group 2) had significantly higher PFS regardless of node-positivity status when compared to those who had not received SL

Resume Objectifs Les nouvelles recommandations de l’Institut national du cancer de janvier 2017 preconisent la realisation d’un test virologique papillomavirus humain (HPV) complementaire lors du diagnostic d’atypies glandulaires au frottis cervicovaginal. L’objectif de cette etude etait d’evaluer la performance du test virologique HPV dans la detection de lesions histologiques cervicales significatives (neoplasie intracervicale [CIN] de grade 2 et plus) en cas de frottis AGC, avant l’application des nouvelles recommandations. Methodes Nous avons mene une etude de cohorte descriptive et retrospective en Alsace entre janvier 2014 et decembre 2016. Nous avons inclus, a partir de la base de donnees de l’association EVE, les patientes ayant presente des atypies glandulaires au frottis cervicovaginal. Resultats Au total, 1074 patientes ont presente un frottis avec atypie glandulaire, soit 0,18 % des frottis. Cent cinquante-deux patientes ont beneficie d’une recherche d’HPV. Nous avons observe 6 cas de CIN2 (3,9 %) et 12 cas de CIN3 (7,9 %). Il n’y a pas eu de diagnostic d’adenocarcinome in situ ou de carcinome invasif. La sensibilite de ce test etait de 88,9 % (IC95 % : [0,65 ; 0,99]), la specificite etait de 65,9 % (IC95 % : [0,55 ; 0,76]), la VPP etait de 34 % (IC95 % : [0,21 ; 0,49]) et la VPN etait de 96,8 % (IC95 % : [0,89 ; 0,99]). Conclusion Le test virologique HPV semble performant dans la prise en charge des atypies glandulaires avec une excellente VPN mais en raison de sa sensibilite moyenne et du risque de progression d’une eventuelle lesion histologique sous-jacente, les recommandations actuelles doivent etre appliquees avec precaution.

To demonstrate the feasibility of outpatient laparoscopic hysterectomy using the assessment of post-operative quality of life.A prospective randomized single-center trial was performed in France between 2013 and 2016. A total of 42 patients needed laparoscopic hysterectomy was included. Postoperative quality of life was assessed using the standardized Euroquol questionnaire. Patients filled the score before the operation and then on the 3rd and 30th postoperative day. Secondary outcomes were assessment of postoperative pain, overall quality of life, analgesic use, and anxiety. The patients were randomized into two groups, group A with a conventional hospital stay of 2 to 3 days and group B with a short stay and a discharge the day after the intervention.Twenty-one patients were randomized to group A as well as group B. We did not find any significant differences between the two groups in our study either on our primary outcome or in the seconds ones. On day 3, the average of Euroquol score was 0.68 for group A against 0.50 for group B (P=0.05). Likewise, the scores for postoperative pain were similar with 70.6 in group A and 61.8 in group B (P=0.21). The trend was the same for quality of life score or anxiety.Our study shows the possibility and the safety of outpatient laparoscopic hysterectomy.

The use of geostatistical methods remains rare in health studies. In order to assess the usefulness of the geostatistical approach in epidemiology, we chose to apply these methods to the vaccination coverage rate (VCR) against human papillomavirus (HPV) in France. Indeed, HPV vaccine coverage remains low in France and geographical disparities are sizable. The objective of this study was to identify the socioecological factors that may explain these geographical variations.Sociological, economic and behavioral data for 2016 have been gathered (demographics and public health database, web and social networks) and were correlated with the HPV VCR vaccine coverage over the French territory. Homogeneous geographical areas defined by strong correlations for groups of variables were selected. In each homogeneous area, principal component analysis was performed and a geostatistical approach provided an estimate predicting vaccine coverage at a given scale.HPV VCR spatial variations in France cannot be fully explained by a single model. In urban areas, a low rate of HPV VCR is preferentially associated with unfavorable socioeconomic factors (poverty, unemployment, immigration). In rural areas, HPV VCR is preferentially associated with sociocultural factors (socio-professional categories, education level, interest in alternative medicines the anti-vaccine movement). Two secondary geographical areas were defined: the Île-de-France region and 12 departments in northeastern France. In the Île-de-France region, the association with the economic factors one again appears as in urban areas in general. The northeasteran departments represent a particular case insofar as HPV VCR is relatively high, notwithstanding economic poverty indicators.Geostatistical modeling successfully identifies new potential explanations for HPV VCR geographical disparities in France. These results could help to adapt or develop future vaccination programs in specific areas by taking into account the sociological, economic and behavioral characteristics of their populations.

The new recommendations by the National Institute of Cancer (January 2017) recommend the use of a complementary human papillomavirus (HPV) virologic test during the diagnosis of atypical glandular cells in pap smear. The aim of this study was the performance analysis of the HPV virologic test for the detection of significant histological cervical abnormalities (CIN2 or more) in case of atypical glandular cells before the new recommendations were published.We performed a descriptive and retrospective cohort study in Alsace between January 2014 and December 2016. We have included, from the EVE-association database, the patients with atypical glandular cells in pap smear.In total, 1074 patients had a pap smear with atypical glandular cells ; 0.18% of total pap smears. This study included 152 patients who had a HPV test. We observed 6 cases of CIN2 (3.9%) and 12 cases of CIN3 (7.9%). No in situ adenocarcinoma nor invasive carcinoma were detected. The sensitivity of the HPV test was 88.9% (95% CI: [0.65; 0.99]), the specificity was 65.9% (95% CI: [0.55; 0.76]), the positive predictive value was 34% (95% CI: [0.21; 0.49]) and the negative predictive value was 96.8% (95% CI: [0.89; 0.99]).The detection of HPV in atypical glandular cells seems to be powerful with an excellent negative predictive value but, because of moderate sensitivity and due to the risk of histologic lesion progression, the current recommendations should to be applied with care.

Ante el descubrimiento de una masa anexial, conviene ante todo descartar una urgencia quirurgica que pueda comprometer la funcion ovarica. Estas urgencias estan dominadas por las torsiones anexiales. En ausencia de urgencia terapeutica, un estudio completo (clinico, pruebas de imagen y biologico) debe permitir estimar el riesgo de malignidad y discutir la indicacion operatoria, asi como la via de abordaje quirurgica. Otros elementos pueden entrar en juego en la indicacion terapeutica: la existencia de infertilidad, en particular en caso de endometriosis, y el riesgo de torsion, sobre todo en caso de quistes de gran tamano. Este articulo revisa de manera practica los principales problemas que se plantean ante el descubrimiento de un tumor ovarico supuestamente benigno.

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 43 - N° 1 - p. 19-25

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 39 - N° 2 - p. 102-115

The current paper presents the second part of chapter 6 of the second edition of the European Guidelines for Quality Assurance in Cervical Cancer Screening. The first part of the same chapter was published in a previous issue (Cytopathology 2008;19:342-54). This part provides guidance on how to manage and treat women with histologically confirmed cervical intraepithelial neoplasia. The paper describes the characteristics, indications and possible complications of excisional and ablative treatment methods. The three options to monitor the outcome after treatment (repeat cytology, HPV testing and colposcopy) are discussed. Specific recommendations for particular clinical situations are provided: pregnancy, immuno-suppression, HIV infection, post-menopause, adolescence and cyto-colpo-histological disparity. The paper ends with recommendations for quality assurance in patient management and some general advice on how to communicate screening, diagnosis and treatment results to the woman concerned. Finally, a data collection form is attached.

The current paper presents the first part of Chapter 6 of the second edition of the European Guidelines for Quality Assurance in Cervical Cancer Screening. It provides guidance on how to manage women with abnormal cervical cytology. Throughout this article the Bethesda system is used for cervical cytology terminology, as the European guidelines have recommended that all systems should at least be translated into that terminology while cervical intraepithelial neoplasia (CIN) is used for histological biopsies (Cytopathology 2007; 18:213-9). A woman with a high-grade cytological lesion, a repeated low-grade lesion or with an equivocal cytology result and a positive human papillomavirus (HPV) test should be referred for colposcopy. The role of the colposcopist is to identify the source of the abnormal cells and to make an informed decision as to whether or not any treatment is required. If a patient requires treatment the colposcopist will decide which is the most appropriate method of treatment for each individual woman. The colposcopist should also organize appropriate follow-up for each woman seen. Reflex testing for high-risk HPV types of women with atypical squamous cells (ASC) of undetermined significance with referral for colposcopy of women who test positive is a first option. Repeat cytology is a second possibility. Direct referral to a gynaecologist should be restricted to special circumstances. Follow-up of low-grade squamous intraepithelial lesion is more difficult because currently there is no evidence to support any method of management as being optimal; repeat cytology and colposcopy are options, but HPV testing is not sufficiently selective, unless for older women. Women with high-grade squamous intraepithelial lesion (HSIL) or atypical squamous cells, cannot exclude HSIL (ASC-H) should be referred without triage. Women with glandular lesions require particular attention. In a subsequent issue of Cytopathology, the second part of Chapter 6 will be presented, with recommendations for management and treatment of histologically confirmed intraepithelial neoplasia and guidance for follow-up of special cases such as women who are pregnant, postmenopausal or immunocompromised.

The current paper presents an annex in the second edition of the European Guidelines for Quality Assurance in Cervical Cancer Screening. It provides guidance on how to make a satisfactory conventional Pap smear or a liquid-based cytology (LBC) sample. Practitioners taking samples for cytology should first explain to the woman the purpose, the procedure and how the result will be communicated. Three sampling methods are considered as acceptable for preparing conventional Pap smears: (i) the cervical broom; (ii) the combination of a spatula and an endocervical brush; and (iii) the extended tip spatula. Smear takers should take care to sample the entire circumference of the transformation zone, to quickly spread the cellular material over a glass slide, and to fix the preparation within a few seconds to avoid drying artefacts. According to local guidelines, one of these three methods may be preferred. Sampling with a cotton tip applicator is inappropriate. Similar procedures should be followed for sampling cells for LBC, but only plastic devices may be used. The collected cells should be quickly transferred into a vial with fixative liquid according to the instructions of the manufacturer of the LBC system. Subsequently, the slide or vial and the completed request form are sent to the laboratory for cytological interpretation.

Resume Les immunomodulateurs representent une classe therapeutique utilisee depuis longtemps deja dans diverses disciplines medicales, mais n'ont fait que recemment leur apparition en gynecologie. Premier produit d'une nouvelle classe therapeutique, l'imiquimod (Aldara ® ) a montre son efficacite dans le traitement des lesions induites par les papillomavirus humains (condylomes acumines, dysplasies cervicales et vulvaires) en stimulant l'immunite du sujet infecte. D'utilisation facile, presentant peu d'effets secondaires, ils semblent offrir la voie therapeutique d'avenir pour ces pathologies virales frequentes, seuls ou en association aux vaccins therapeutiques ou aux traitements destructeurs en prevention des recidives. Ce travail propose de faire le point sur le mecanisme d'action des differents immunomodulateurs, leurs indications et leur efficacite en pratique gynecologique.

Mifepristone, a derivative of norethindrone, a first generation synthetic progestative, has a very potent antiprogestative activity and to a lesser degree antiandrogenic and antiglucocorticoid activities. This action makes it potentially useful in the treatment of multiple hormone dependent diseases in obstetrics-gynecology as well as in a variety of medical specialties such as neurology, ophthalmology, and oncology. Nevertheless, the label of abortive pill has incited numerous ethical and political debates concerning the permission to market this drug, and this has contributed to the delay in the assessment of the potential indications of mifepristone. Largely under-utilized in practice despite its increasing theoretical benefit, clinical studies should now de conducted. Thus, based on an international review of literature during the last ten years, we have shed light on the present and potential indications of mifepristone in medical practice.

Background. The initial manifestation of a lymphoma as an ovarian mass is unusual, with a reportedly poor prognosis. An exploratory laparotomy is often performed as the ovarian tumor can mimic an advanced epithelial carcinoma. The criteria of lymphoma used in the selection of a nonsurgical approach, that is, chemotherapy possibly associated with radiation, are rarely defined. Case. We report the case of a 36-year-old woman who presented with an ovarian tumor suggestive of advanced carcinoma. After an initial approach including optimal surgery, the diagnosis of large B-cell CD30+ non-Hodgkin malignant lymphoma was established. Complete remission was obtained after a chemotherapy regimen, appropriate to the specific histologic type of the lymphoma. Conclusion. The choice treatment of ovarian non-Hodgkin lymphoma (NHL) is chemotherapy. In the presence of an ovarian tumor, the possibility of ovarian NHL must be considered, and its clinical, biological, and/or radiological signs must be actively sought. Controlled biopsies must also be included to avoid mutilating surgery.

Resume Objectif Evaluer la fiabilite du curetage endocervical (CEC) chez des patientes prealablement traitees pour une neoplasie cervicale intraepitheliale (CIN). Patientes et methodes Analyse retrospective d’une serie continue de 85 patientes vues en colposcopie dans le cadre de la surveillance post-therapeutique entre janvier 1985 et decembre 2011 et ayant beneficie d’un CEC en raison d’une anomalie colposcopique endocervicale incompletement visible ou inaccessible a la biopsie, de la presence d’atypies glandulaires au frottis, ou d’une discordance entre l’aspect colposcopique et le frottis. La fiabilite du CEC etait evaluee par comparaison a l’analyse histologique definitive de la piece operatoire ou en l’absence d’exerese par les donnees de la surveillance cyto-colpo-histologique ulterieure. Resultats Les patientes ont ete vues en colposcopie entre 6 et 240 mois apres le traitement initial d’une CIN et presentaient une lesion residuelle ou recidivante endocervicale dans 36 cas (42,4 %) dont deux cancers micro-invasifs et un adenocarcinome. La colposcopie etait non satisfaisante chez 75,3 % des patientes et l’aspect colposcopique exocervical juge normal chez 80 % des patientes. Une concordance parfaite entre le diagnostic pose au CEC et le diagnostic endocervical final a ete notee chez 68 patientes (80 %). Pour le diagnostic de lesions cervicales severes (CIN 2+), le CEC presente une sensibilite de 86,2 % (68,3–96,1), une specificite de 94,6 %, (85,1–98,9) et des valeurs predictives positive et negative de respectivement 61,4 % (47,6–74) et 93 % (83–98,1). Conclusion La fiabilite du CEC pour les lesions endocervicales severes en fait un outil tres utile pour la colposcopie post-therapeutique permettant de reduire le nombre de traitements iteratifs, sans majorer le risque d’evolution d’une lesion vers le cancer.

Resume But de l’etude : La chirurgie des cancers avances de l’ovaire a pour but d’obtenir un residu tumoral minimal necessitant parfois des exereses digestives. Patientes et methodes : La survie globale et sans rechute, la morbidite et mortalite postoperatoires de soixante-deux patientes presentant un cancer de l’ovaire de stade III ont ete etudiees retrospectivement en fonction de differents parametres (stade, grade histologique, residu tumoral postoperatoire, vitesse de normalisation du CA 125 , complications postoperatoires et duree d’hospitalisation). Deux groupes de patientes etaient individualises en fonction de la chirurgie pratiquee (groupe 1 : chirurgie gynecologique et digestive 〚 n = 17〛 ; groupe 2 : chirurgie gynecologique exclusive 〚 n = 45〛). Toutes les patientes etaient traitees par une polychimiotherapie adjuvante a base de sel de platine. L’âge moyen etait de 60 ans (extremes : 20–83). Sept stades IIIa, dix stades IIIb et 45 stades IIIc etaient repertories. Resultats : La mortalite postoperatoire etait de 3,5 % (2/62). La morbidite postoperatoire de 26 % (13/62). La realisation d’une resection gastro-intestinale et/ou d’une splenectomie n’influencait ni la duree d’hospitalisation globale, ni la duree d’hospitalisation en unite de soins intensifs, ni la morbidite aspecifique ou specifique liee a l’acte chirurgical. La survie globale a cinq ans etait de 56 %. Seul un residu tumoral postoperatoire de moins de 2 cm 3 est un element influencant la survie globale (56 % versus 23 % ; p = 0,03) et la survie sans rechute (84 contre 46 % ; p = 0,02). Conclusion : Les exereses digestives necessaires a l’obtention d’un residu tumoral postoperatoire minimal ne semblent pas accroitre la mortalite ni la morbidite postoperatoire de la chirurgie des cancers avances de l’ovaire.

Health-related quality of life (QoL) in patients treated for ovarian cancer is directly and heavily impacted by the natural history of cancer, its evolution and its therapeutic modalities. The evaluation and consideration of various parameters of QoL seems to be a major issue. Indeed, on the one hand, it is essential to take into account the opinion of patients in the choice of therapeutic strategies for this cancer with a poor prognosis and, on the other hand, more and more studies show that QoL is an independent prognostic factor in ovarian cancer. Improvement in this case, in addition to being an endpoint by itself, would potentially improve the overall survival of patients. To date there are several tools to assess QOL of patients with ovarian cancer. The 2 questionnaires most commonly used are: FACT-O and the EORTC QLQ-OV28. The aim of our study was to evaluate from a review of the literature, the reciprocal effects of ovarian cancer on QoL and QoL on ovarian cancer survival, as well as specificities of each of the 2 questionnaires most commonly used in assessing the QoL.

Authors report a left colon ischemia six days after laparoscopic para-aortic lymphadenectomy in the staging of advanced cervical carcinoma. Before surgery, positron emission tomography scanning was performed: there were no para-aortic nodal metastasis. The histologic examination confirmed the radiological staging. Positron emission tomography scanning could avoid surgery in the case of patients with high risks morbidity factors.

There is strong epidemiological and biological evidence that the development of squamous cell carcinoma of the cervix is a multistep process in which human papillomaviruses (HPVs) play a crucial but not total role and where the synergistic effect of herpes simplex virus (HSV) and human cytomegalovirus (HCMV) has been suggested. The presence of HPV, HSV and HCMV deoxyribonucleic acids (DNAs) was assessed by a polymerase chain reaction(PCR) in cervical biopsies obtained from 41 women with cervical neoplasia (21 high-grade cervical intra-epithelial neoplasia (CIN) and 20 squamous cell cancers) and 33 controls. Human papillomavirus 16 DNA was significantly more common in high-grade CIN (57%) and cancer (50%) than in normal cervix (9%). Herpes simplex virus and HCMV DNAs were present in 12% and 21% of normal cervices, 19% and 24% of high-grade CIN, and 25% and 25% of cancers, respectively. After adjustment for patients9 age, coinfection associating high-risk HPVs (HPV 16 and/or HPV 18) and herpes viruses (HCMV and/or HSV) were observed in cervical neoplasia (odds ratio (OR) = 19.11; 95% confidence interval (CI): 2.14-170.36). Conversely, the OR for infection by HPV 16 and/or HPV 18 alone did not reach statistical significance (OR = 7.22; 95% CI: 0.85-61.16). Moreover infection by HCMV and/or HSV alone(OR = 0.89; 95% CI: 0.33-2.24) was not associated with cervical neoplasia. Our results support the role of HSV and HCMV as cofactors of HPV 16 and HPV 18 in cervical neoplasia.

Recent epidemiological data suggest an increase of the incidence and prevalence of CIN as well as a decrease of the mean age of the patients presenting these lesions. Large loop electrosurgical procedure (LEEP) is the most commonly used treatment method. According to recent studies LEEP provides a 1.4 to 7.0 fold increase of preterm delivery. Cervical cerclage does not show efficiency in reducing this risk, even if cervical shortening is measured by transvaginal ultrasound. Considering histological severity of lesions and the age of patients, number of currently conducted conizations in France could be avoided and so their obstetrical consequences prevented, just because no treatment is necessary or could be done by ablative procedures.

The obstetrical consequences of conisation for cervical intraepithelial neoplasia (CIN) should be considered since patients affected by these lesions are actually younger and most often desire further pregnancies. The loop electrosurgical excision procedure (LEEP), which is currently mostly used, achieves cure rate varying according to the authors between 80 and 95%. However, the most recent data show an increase of obstetrical morbidity, especially prematurity, after LEEP excision. As the frequency and severity of prematurity is correlated to the size and depth of the LEEP, we should minimize as much as possible the resection for these young patients.

Summary With the same aspect o f multiple peritoneal leiomyomas, the diagnosis o f typical leiomyomatosis peritonealis disseminata was established in two women aged 43 and 49, while in a third case the mature metastasis o f a primary low-grade bilateral ovarian stromal sarcoma in a woman aged 63 was diagnosed.

Objective To assess the prevalence of human papillomavirus (HPV) type 16 and 18, herpes simplex virus (HSV) and human cytomegalovirus (HCMV) in cervical biopsies in order to evaluate their relationship in cervical intraepithelial neoplasia (CIN) and cancer. Setting Colposcopy clinic; Service de Gynecologie-Obstetrique I, Hopital de Hautepierre, Hopitaux Universitaires de Strasbourg and Laboratoire Commun ULP/Synthelabo et U74 INSERM, Institut de Virologie de la Faculte de Medecine de Strasbourg, France. Subjects Forty-two women with low grade and high grade CIN, twenty women with cervical squamous cancer and twenty-two women with normal cervix assessed by cytological, colposcopical and histological analysis. Methods Viral DNA was detected by PCR technique in colposcopically directed biopsies. Results The prevalence of HPV16 and/or HPV18 with HSV and/or HCMV was significantly higher in cancers (25%) or high grade CIN (29%) than in normal cervices (0%). On the contrary, when only HPV DNA was found, there was no significant difference between cancers (30%), high grade CIN (29%) and normal cervices (9%). Conclusions The results support the hypothesis of a role of herpes viruses (HSV and HCMV) as cofactors in cervical carcinogenesis.

To assess the relevance of MRI, endometrial biopsy and curettage in the diagnosis of endometrial cancer at high risk of lymph node metastasis.A retrospective study on continuous series of patients treated for endometrial cancer limited to the uterus between 2004 and 2008, results of preoperative evaluation of tumor stage using MRI, histological type and grade by endometrial curettage and biopsies were compared to final histological examination.One hundred and sixty-nine patients were included in the study. Ninety (53.3%) had MRI, 112 (66.2%) curettage and 61 (36.6%) endometrial biopsy using Pipelle de Cornier. Sensibility (SN), specificity (SP), positive (PPV) and negative predictive values (NPV) of MRI, in the diagnosis of endometrial cancer at high risk of lymph nodes metastases were of 65.6%, 87.2%, 77.7%, 79.2%. For EB and curettage SN, SP, PPV and NPV were of 42.9%, 96.9%, 85%, 79.5%; 80.6%, 98.3%, 96.2% and 90.6% respectively. 37.8% of cancers diagnosed to be at low risk of lymph node metastasis were at high risk in definitive histologic examination.Preoperative evaluation by MRI, endometrial curettage and biopsy has good diagnostic value in the identification of endometrial cancer susceptible to benefit from lymphadenectomy. Underestimation, however, is encountered in approximately one third of cases.

Pap smear screening of women under 25 years old remains controversial. No randomized study exists on this topic. The perception of individual benefit often prevails, although there is no proof of effectiveness and no demonstrated risk-benefit ratio. A review of published studies - taking into account epidemiological data, effectiveness of screening of young women, adverse medical outcomes and costs - suggests that there are more arguments against screening before 25 than in favour of it.

La colposcopie est essentielle pour le diagnostic des cancers debutants, generalement asymptomatiques, decouverts grâce au depistage. Il n’y a pas de criteres pathognomoniques pour le diagnostic de la microinvasion a la colposcopie, mais il y a des associations d’images elementaires suspectes qui l’evoquent et ce d’autant plus que la patiente a plus de 40 ans et/ou que la cytologie l’avait evoque au depart. La colposcopie non satisfaisante et la grande taille des lesions ont ete identifiees comme des facteurs independants associes au non-diagnostic de la micro-invasion a la colposcopie. Par ailleurs, la grossesse constitue une situation ou l’interpretation colposcopique est particulierement difficile.

The current paper presents an annex in the second edition of the European Guidelines for Quality Assurance in Cervical Cancer Screening. It provides guidance on how to make a satisfactory conventional Pap smear or a liquid-based cytology (LBC) sample. Practitioners taking samples for cytology should first explain to the woman the purpose, the procedure and how the result will be communicated. Three sampling methods are considered as acceptable for preparing conventional Pap smears: (i) the cervical broom; (ii) the combination of a spatula and an endocervical brush; and (iii) the extended tip spatula. Smear takers should take care to sample the entire circumference of the transformation zone, to quickly spread the cellular material over a glass slide, and to fix the preparation within a few seconds to avoid drying artefacts. According to local guidelines, one of these three methods may be preferred. Sampling with a cotton tip applicator is inappropriate. Similar procedures should be followed for sampling cells for LBC, but only plastic devices may be used. The collected cells should be quickly transferred into a vial with fixative liquid according to the instructions of the manufacturer of the LBC system. Subsequently, the slide or vial and the completed request form are sent to the laboratory for cytological interpretation.

Immunomodulators have been used for some time in various medical specialities, but have only recently been used in gynaecology. The first drug in this therapeutic class, Immiquimod (Aldara), has been shown to be effective in treating lesions induced by Human Papillomavirus (HPV) such as genital warts or cervical and vulvar dysplasia, by stimulating the immune system of an infected individual. Thanks to its ease of use and its few side effects, Imiquimod would appear to be, in the future, the treatment of choice for these types of viral infections, alone or in association with therapeutic vaccines or physical abative therapies as a prevention of relapses. This review aims at summarizing and clarifying the mechanism of action of the different immunomodulators, their indications and their effectiveness in gynecologic practice.

Convaincre les femmes de participer est en effet fondamental puisque l’on constate que 52 a 72 % des cancers du col surviennent chez des patientes qui ont eu un depistage insuffisant voir inexistant (1, 2, 3, 4, 5, 6). De plus, l’absence de depistage est souvent associee a un cancer decouvert a un stade plus avance (3, 7). Dans les pays ou le depistage est organise, la reduction de l’incidence du cancer invasif est parfaitement correlee au taux de participation de la population (8, 9, 10). Bien que la pratique du frottis soit largement repandue en France, le depistage par son caractere opportuniste presente une repartition tres irreguliere selon les femmes. Globalement, environ 40 % des femmes francaises n’ont jamais eu de frottis et ce taux augmente avec l’âge (8). L’implication des medecins generalistes dans le depistage est faible en France. Cela contribue a la maigre participation des femmes âgees ou de conditions socio-economiques limitees puisque celles-ci consultent plus rarement un gynecologue (3, 12). Plus le niveau d’instruction est eleve, plus les femmes connaissent le frottis cervical et en beneficient. Neanmoins, l’ecart entre la connaissance des recommandations et leur application est important et augmente avec l’âge. Une enquete menee dans le departement du Bas-Rhin en 1989 aupres d’un echantillon representatif de 500 femmes a demontre que 98 % La communication vers les femmes et leur information

Authors report a left colon ischemia six days after laparoscopic para-aortic lymphadenectomy in the staging of advanced cervical carcinoma. Before surgery, positron emission tomography scanning was performed: there were no para-aortic nodal metastasis. The histologic examination confirmed the radiological staging. Positron emission tomography scanning could avoid surgery in the case of patients with high risks morbidity factors.

Mifepristone, a derivative of norethindrone, a first generation synthetic progestative, has a very potent antiprogestative activity and to a lesser degree antiandrogenic and antiglucocorticoid activities. This action makes it potentially useful in the treatment of multiple hormone dependent diseases in obstetrics-gynecology as well as in a variety of medical specialties such as neurology, ophthalmology, and oncology. Nevertheless, the label of abortive pill has incited numerous ethical and political debates concerning the permission to market this drug, and this has contributed to the delay in the assessment of the potential indications of mifepristone. Largely under-utilized in practice despite its increasing theoretical benefit, clinical studies should now de conducted. Thus, based on an international review of literature during the last ten years, we have shed light on the present and potential indications of mifepristone in medical practice.

We describe a case of unilateral tibial agenesis which was initially observed at 21 weeks' gestation. Unlike bilateral tibial hemimelia syndrome, a rare autosomal dominant condition, unilateral tibial agenesis, which accounts for about three-quarters of all newborns with this condition, has not previously been described. This case could have been a sporadic abnormality but, in view of the association with other observations (distal bifurcation of the femur, club foot), could be considered as an autosomal recessive inherited condition with variable penetrance. Ultrasonographic features and the genetic prognosis are discussed. Copyright © 1996 International Society of Ultrasound in Obstetrics and Gynecology

The initial manifestation of a lymphoma as an ovarian mass is unusual, with a reportedly poor prognosis. An exploratory laparotomy is often performed as the ovarian tumor can mimic an advanced epithelial carcinoma. The criteria of lymphoma used in the selection of a nonsurgical approach, that is, chemotherapy possibly associated with radiation, are rarely defined.We report the case of a 36-year-old woman who presented with an ovarian tumor suggestive of advanced carcinoma. After an initial approach including optimal surgery, the diagnosis of large B-cell CD30+ non-Hodgkin malignant lymphoma was established. Complete remission was obtained after a chemotherapy regimen, appropriate to the specific histologic type of the lymphoma.The choice treatment of ovarian non-Hodgkin lymphoma (NHL) is chemotherapy. In the presence of an ovarian tumor, the possibility of ovarian NHL must be considered, and its clinical, biological, and/or radiological signs must be actively sought. Controlled biopsies must also be included to avoid mutilating surgery.

Based on the 7-years results, assess the interest of organised cervical cancer screening on regional level (the EVE campaign). ORGANISATION AND METHOD: The screening relied on existing medical structures. The centralised data collection, with data from the cyto-pathology laboratories assessed the quality of screening and the participation of the women to the follow-up of abnormal smears. The campaign run by a local women's rights association and sponsored by National educational and health information funds (FNPEIS) and the local councils.To date, 814 649 smears in the Bas-Rhin and 62 227 in the Haut-Rhin have been collected. After 3 years, 72% of women aged 25 to 64 in the year 1997, in the Bas-Rhin, had had at least one smear, and 82% after 5 years. Inadequate smears represented less than 1% of all smears of the region. Pathological smears represented around 4% of the total and benefited from strict monitoring which could be improved. However this could be improved on since only 75% of women in whom a low-grade lesion was suspected underwent a second examination within the year that followed. The rate was on 80% for those with suspected high-grade lesions. Reminders made by the EVE association, in agreement with practitioners, permitted postponed follow-up and improved screening coverage.The EVE programme clearly shows that organized screening is feasible in France because the results obtained are satisfactory in terms of screening coverage and quality of smears. Centralised data collection permits detection of possible weak points and contributes to the improvement in efficacy.

Digestive surgery is often necessary for surgical management of advanced ovarian carcinoma.In a series of 62 patients with stage III ovarian carcinoma, postoperative morbidity and mortality, overall survival after 5 years and disease-free survival after 2 years were studied and corelated with several patients criteria (age, stage of the disease, residual disease, type of surgery, CA125 normalisation delay, postoperative complications and hospital stay). Patients were divided into two groups according to the surgical treatment. The first group (n = 17) included patients treated by gynecologic and digestive surgery, the second group (n = 45) included patients treated by gynecologic surgery only. All patients were proposed for chemotherapy included platyn salt. Mean age was 60 years (range: 20-83). The stage of the cancer was stage IIIa in 7 cases, stage IIIb in ten and stage IIIc in 45.Postoperative mortality was 3.5% (2/62). Postoperative morbidity was 26% (13/62). No statistical differences were noted for hospital stay, general morbidity, surgical morbidity when a gastric resection or a colon resections or a splenectomy were performed. Overall survival at 5 years was 56%. Residual disease less than 2 cm3 is the only prognostic factor for overall survival (56% vs 23% [P = 0.03]) and disease-free survival (86% vs 46% [P = 0.02]).This study including 62 patients confirmed the prognostic significance of extensive cytoreductive surgery for treatment in advanced ovarian epithelial cancer without increasing the postoperative morbidy and mortality.