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Resume De nombreuses femmes ayant ete traitees pour tumeur frontiere de l’ovaire (TFO) sont concernees par les questions de contraception et de traitement hormonal de la menopause ou substitutif (THM/THS). Objectifs Synthetiser les connaissances sur les risques de TFO lies a la contraception hormonale et au THM/THS, et emettre des recommandations sur la contraception et le THM/THS apres TFO. Methodes Revue systematique de la litterature concernant contraception hormonale et TFO et THM/THS et TFO (realisee sur PubMed/Medline et la Cochrane Library). Resultats Il n’existe pas de donnees concernant l’utilisation de contraception hormonale apres TFO. L’utilisation d’une contraception orale (ou un antecedent d’utilisation) est associee a une tendance a la reduction du risque de TFO sereuse, et a un effet moins marque voire neutre sur le risque de TFO mucineuse. L’utilisation de contraception hormonale apres une TFO sereuse ou mucineuse n’est ainsi pas contre-indiquee (grade C). Une tendance a l’augmentation du risque de TFO sereuse liee a la prise de THM/THS est retrouvee contrairement au risque de TFO mucineuse qui ne semble pas modifie (grade C). En cas d’antecedent de TFO presentant des criteres histologiques pejoratifs (contingent micropapillaire, micro-invasion, implants peritoneaux), compte tenu du risque accru de recidive sous forme infiltrante, hormonosensible, l’utilisation d’un THM/THS ne pourra etre envisagee qu’au cas par cas, avec prudence, apres discussion pluridisciplinaire. Apres traitement d’une TFO mucineuse ou sereuse sans criteres histologiques pejoratifs, un THM/THS peut etre utilise (grade C). Conclusion Les contraceptions hormonales peuvent etre utilisees apres TFO. Les caracteristiques histologiques de la tumeur doivent etre prises en compte pour decider de l’utilisation d’un THS/THM.

Introduction/Background* Epithelial ovarian cancer (EOC) requires an aggressive surgical approach. The type and the number of procedures performed during primary (PDS) or interval (IDS) debulking surgery in order to achieve no residual disease are associated with considerable morbidities. The objective is to describe a relationship among surgical complexity, early and late morbidities, and surgical timing in advanced EOC. Methodology A retrospective study was performed at Leon Berard Cancer Center between 2006 and 2018. Surgical complexity was classified into three groups (standard, radical and ultra-radical surgery) based on the type and the number of procedures performed during PDS or IDS for advanced EOC. During the 30- and 90-day period after the surgery, the post-operative complications were registered according to the Clavien-Dindo classification. Result(s)* 311 patients with advanced EOC were included. 84 patients underwent PDS (27%) and 227 IDS (73%), respectively. No residual disease was achieved in 258 out of 311 patients (83%). Standard surgery was performed in 80 patients (25.7%), radical surgery in 45 patients (14.5%) and ultra-radical surgery in 186 patients (59.8%). No residual disease was reached in 72 out of 80 standard surgery (90%), 37 out of 45 radical surgery (82.2%) and 149 out of 186 (80.1%) ultra-radical surgery. Early and late severe (G3-4) complications were present in 32/311 patients (10.3%) and 23/311 patients (7.4%), respectively. Increased postoperative morbidity was directly related to the following perioperative factors: HIPEC [OR 4.4 (1.0-20)], addition of each single surgical procedures to the standard surgery [OR 1.3 (1.1-1.5)], number of surgical procedures added to modified pelvic posterior exenteration [OR 1.4 (1.1-2.0)], surgical complexity [SR vs S or R; OR 2.4 (1.1-5.7)]. In multivariate analysis, OS is not correlated with surgical complexity [OR 1.0(0.5-2.1)] and with the burden of early [OR 0.7(0.3-1.5)] or late [OR 0.7(0.3-1.7)] severe complications. Conclusion* Despite surgical timing, ultra-radical-surgery is needed to reach no residual disease in >80% of our patients. The risk of early and late severe morbidities is increased for complex surgeries but they don’t affect OS. Risk stratification should be used to plan perioperative care and best treatment.

Contraceptive options and menopause management are frequent clinical issues among women previously treated for a borderline ovarian tumour (BOT).To synthesize knowledge on BOT and risk related to hormonal contraception and to menopausal hormone therapy (MHT), and to propose recommendations on contraception and MHT after BOT treatment.Systematic review of the literature about hormonal contraception and BOT and on MHT and BOT was conducted on PubMed/Medline and the Cochrane Library.There are no data concerning hormonal contraception after BOT. Current or previous oral contraception is associated with a trend towards decreased risk of serous BOT. Mucinous BOT risk is not or slightly decreased by oral contraception. Hormonal contraception is thus not contraindicated in women previously treated for a BOT (grade C). MHT is associated with a trend towards increased risk of serous BOT. No relation was found between MHT and risk of mucinous BOT. Serous BOTs with high-risk histological criteria (micropapillary pattern, stromal microinvasion or peritoneal implants) are at high-risk of invasive potentially hormone-sensitive recurrence. Hence, caution is needed in the decisions of using MHT after serous BOT with one of these high-risk histological criteria, and MHT should be discussed on a case to case basis. MHT can be prescribed without restriction in women previously treated for mucinous and serous BOT without high-risk histological criteria (grade C).Hormonal contraception can be used after BOT. The histological characteristics of the tumour must be taken into account when deciding on the use of HRT/THM.

Breast cancer is the most commonly diagnosed type of cancer among women. For the last fifteen years, treatments that are less invasive than lumpectomy, such as high-intensity focused ultrasound (HIFU) therapy, have been developed, with encouraging results. In this study, a toroidal HIFU transducer was used to create lesions of at least 2 cm in diameter within less than one minute of treatment. The toroidal HIFU transducer created two focal zones that led to large, fast and homogeneous ablations (10.5 cc/min). The experiments were conducted in 30 human samples of normal breast tissues recovered from mastectomies to measure acoustic attenuation (N = 30), and then, HIFU lesions were created (N = 15). Eight HIFU ablations were performed to evaluate the reproducibility of the lesions. HIFU lesions were created in 45 s with a toroidal HIFU transducer working at 2.5 MHz. The longest and shortest axes of the HIFU lesions were 21.7 ± 3.1 mm and 23.5 ± 3.3 mm respectively, corresponding to an average volume of 7.3 ± 1.4 cm3. These HIFU lesions were performed at an average depth of 19.0 ± 1.5 mm, while the integrity of the skin was preserved. The HIFU-treated breast tissues had a higher level of attenuation (0.57 ± 0.11 Np.cm−1.MHz−1) when compared to the untreated tissues (0.21 ± 0.04 Np.cm−1.MHz−1). This study shows the feasibility of a fast and fully noninvasive treatment using a toroidal transducer for breast tumors measuring up to 15 mm in diameter.

International audience; BACKGROUND:Pelvic exenteration remains one of the most mutilating procedures, with important postoperative morbidity, an altered body image, and long-term physical and psychosocial concerns. This study aimed to assess quality of life (QOL) during the first year after pelvic exenteration for gynecologic malignancy performed with curative intent.METHODS:A French multicentric prospective study was performed by including patients who underwent pelvic exenteration. Quality of life by measurement of functional and symptom scales was assessed using the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30 (version 3.0) and the EORTC QLQ-OV28 questionnaires before surgery, at baseline, and 1, 3, 6, and 12 months after the procedure.RESULTS:The study enrolled 97 patients. Quality of life including physical, personal, fatigue, and anorexia reported in the QLQ-C30 was significantly reduced 1 month postoperatively and improved at least to baseline level 1 year after the procedure. Body image also was significantly reduced 1 month postoperatively. Global health, emotional, dyspnea, and anorexia items were significantly improved 1 year after surgery compared with baseline values. Unlike younger patients, elderly patients did not regain physical and social activities after pelvic exenteration.CONCLUSIONS:Therapeutic decision on performing a pelvic exenteration can have a severe and permanent impact on all aspects of patients' QOL. Deterioration of QOL was most significant during the first 3 months after surgery. Elderly patients were the only group of patients with permanent decreased physical and social function. Preoperative evaluation and postoperative follow-up evaluation should include health-related QOL instruments, counseling by a multidisciplinary team to cover all aspects concerning stoma care, sexual function, and long-term concerns after surgery.

Resume Objectifs Il s’agit d’une etude retrospective reprenant l’ensemble des Curages Axillaires complementaires (CAc) realises dans l’annee suivant un geste de reconstruction mammaire par lambeau de grand dorsal pedicule avec transfert dans la region thoracique anterieure par un tunnel axillaire. Methodes La technique operatoire est precisee, ainsi que les suites postoperatoires et les sequelles tardives observees. Resultats De 1999 a 2013, 21 CAc ont ete realises. Les suites postoperatoires ont ete simples dans 85 % des cas en respectant le protocole operatoire detaille dans ce travail. Aucune necrose partielle ou totale du sein reconstruit n’a ete observee. Avec un suivi median de 64 mois, 6 patientes (28 % de la population) ont presente au moins une sequelle a type de sensation de lourdeur du bras ( n = 2, 9 %) ou un lymphœdeme ( n = 3, 14 %), douleurs chroniques ( n = 4, 19 %) ou une limitation des mouvements ( n = 2, 9 %). Conclusion La realisation d’un CAc est faisable apres une procedure de reconstruction mammaire immediate par lambeau de grand dorsal, et aucune morbidite operatoire surajoutee ne semble etre associee comparee a une procedure standard.

Resume Objectif Analyse des complications et de la survie de la chirurgie de cytoreduction comportant une exenteration pelvienne posterieure modifiee selon Hudson dans le traitement chirurgical des tumeurs malignes ovariennes. Methodes Etude retrospective monocentrique continue realisee au centre de lutte contre le cancer de la region Rhone-Alpes entre 2000 et 2013. Inclusion de 152 patientes atteintes d’un cancer ovarien et traitees par une chirurgie comportant une exenteration posterieure modifiee selon Hudson. Analyse des complications dans les 30 jours postoperatoires selon la classification de Clavien-Dindo. Resultats Dans notre etude, le taux de complications globales etait de 62,5 % avec un taux de complications graves de 7,9 %. Notre taux de resection complete etait de 82,2 %. Trois fistules (2,2 %) ont ete mises en evidence. En moyenne, il y a eu 6,6 ± 1,8 (2–11) gestes chirurgicaux associes a la resection de Hudson lors de la chirurgie. En analyse univariee, il existait une association statistiquement significative entre les complications a partir du grade II de la classification de Clavien-Dindo et la chirurgie supraradicale, la chirurgie post-chimiotherapie, la chirurgie des recidives, la resection d’une coupole diaphragmatique, et la resection gastrique partielle. Cette association statistiquement significative a ete egalement observee avec le nombre de gestes chirurgicaux associes a la resection de Hudson. Conclusion Le principal facteur pronostique chirurgical du cancer ovarien est l’obtention d’un residu tumoral nul. L’exenteration pelvienne posterieure modifiee selon Hudson permet de l’obtenir. Notre etude montre un taux faible de complications graves suite a ce type de geste chirurgical.

Resume Objectif L’objectif de cette etude est d’evaluer la satisfaction des patientes operees d’un cancer du sein en unite de chirurgie ambulatoire et de la comparer a la satisfaction en hospitalisation traditionnelle. Patientes et methodes Il s’agit d’une etude observationnelle longitudinale prospective s’interessant a toutes les patientes operees de tumeur mammaire maligne pour une meme intervention (tumorectomie avec recherche du ganglion sentinelle) entre juillet et decembre 2013, dans un centre de lutte contre le cancer. Les patientes etaient interrogees selon un questionnaire preetabli, le jour de la chirurgie, puis 30 jours plus tard. Resultats Cent cinquante-cinq patientes (toutes des femmes) ont ete incluses, dont 102 dans le groupe ambulatoire et 53 dans le groupe hospitalisation traditionnelle. Aucune difference en termes de satisfaction n’etait retrouvee entre les deux groupes le jour de la chirurgie (p = 0,20) et a 30 jours (p = 0,35) ; 101 (99 %) patientes d’ambulatoire et 44 (95,7 %) patientes en hospitalisation traditionnelle etaient ainsi tres satisfaites ou jugeaient leur satisfaction excellente le jour de la chirurgie contre 88 (92,7 %) et 49 (98 %) a 30 jours. La note moyenne de satisfaction globale attribuee par les patientes etait de 9,1 ± 1,2 [3–10] le jour de la chirurgie et de 8,7 ± 1,3 [3–10] a 30 jours, tous types de prise en charge confondus. Discussion et conclusion Nous rapportons un haut degre de satisfaction des patientes operees pour une tumeur mammaire en ambulatoire, non different de celui des patientes en hospitalisation traditionnelle. La prise en charge ambulatoire pour ce type de chirurgie semble une alternative valable a l’hospitalisation conventionnelle.

We report two cases of spontaneous regression of breast cancer occurred in our institution. It was about a 34- and an 82-year-old patient. The examination revealed a palpable nodule. In both cases, biopsy revealed a negative immunohistochemical staining for estrogen and progesterone receptors, and HER-2 negative. Histological analysis of the surgical specimen found fibrous tissue rearrangement without carcinoma. In the first case, a sarcoidosis was diagnosed at the same time, the mediastinal nodes mimicked a metastatic cancer. These cases illustrate a rare phenomenon. The main hypothesis is a carcinoma- directed immune response triggered by the biopsy.

National audience

The objective of the study is to determine whether surgery influences the outcome of stage IV ovarian cancer. The study design is as follows: From May 1995 to December 2000, 129 patients with FIGO stage IV ovarian cancer, recruited in 42 centers, were prospectively included in GINECO first-line randomized studies of platinum-based regimens with paclitaxel administered simultaneously or sequentially. In all, 109 were eligible for this study. Standard peritoneal cytoreductive surgery was defined as a procedure including at least total hysterectomy, bilateral salpingo-oophorectomy, omentectomy, and peritoneal debulking. Surgery was considered optimal if residual lesions were smaller than 1 cm. The Kaplan-Meier method was used to compare survival. Initial abdominopelvic cytoreductive surgery was considered standard in 55 (54%) patients. Abdominopelvic surgery was optimal in 29 patients and nonoptimal in 26. Twenty-two (22%) patients had a simple biopsy, and 25 (24%) patients underwent substandard surgery. Twenty-two of these 47 patients without initial standard surgery underwent a second surgical procedure, and 17 of the 22 patients completed standard surgery. The median overall survival time in the entire population was 24.3 months (95% confidence interval [CI], 19.5-29.1 months). Patients treated without a cytoreductive surgical procedure had significantly worse median survival (15.1 months; 95% CI, 5.4-24.9 months) than patients who had optimal primary surgery (22.9 months; 95% CI, 15.6-30.1 months), nonoptimal primary surgery (27.1 months; 95% CI, 21.2-32.9 months), or neoadjuvant chemotherapy followed by surgery (45.5 months; 95% CI, 23.5-67.5 months) (P= .001). In conclusion, this study shows a significant benefit of debulking surgery in stage IV ovarian cancer patients who responded to neoadjuvant chemotherapy. Neoadjuvant chemotherapy can help to select patients for surgery.

The biphasic waveform (BPW) is an abnormality of the optical transmission waveform obtained during measurement of the activated partial thromboplastin time on a specific photometric haemostasis autoanalyzer. This abnormality is related to calcium-dependent formation of complexes between C reactive protein and very low density lipoprotein. Biphasic waveform had a high sensitivity and negative predictive value for the identification of patients with severe sepsis and septic shock. On day 3, the time course of the biphasic waveform is a marker for the prognosis of sepsis-related mortality. The BPW is not a surrogate marker for C-reactive protein or procalcitonin and provides additional information. Further trials should be necessary using BPW for diagnostic and management procedures. Compared with other laboratory markers such as C reactive protein or procalcitonin, activated partial thromboplastin time waveform analysis is a tool that is rapid, inexpensive, effective and available 24 hours a day. When the analyzer is locally available, waveform analysis of this routine coagulation test provides information for the diagnosis of severe sepsis and the prognosis of septic patients.

Isolated axillary lymph node metastases is an unusual clinical presentation of breast carcinoma. We studied its different issues.This study is a follow-up study of 16patients, treated between 1996 and 2012, presenting with axillary metastases with an occult breast carcinoma, which could not be identified by physical examination nor by a conventional imaging or a breast MRI. Clinical characteristics, histological analysis, treatment, monitoring and five-year survival rate were studied.The incidence of this kind of breast cancer was 0.20%. A breast MRI was performed in 75% of the patients. The histology of these tumors showed a rate of hormono-sensibility of 50% and an HER2 overexpression of 44%. Sixty-nine percent of the patients had no breast surgery or radiotherapy; global five-year survival rate for these women was 77.4%±11.5.The survival rates of this study should lead the practitioner to choose a less aggressive breast therapy. Moreover, the histological characteristics explain the high metastatic potential of these tumors, and relate them to the HER2+ subclass of gene expression patterns of breast carcinomas.

Resume Objectif Evaluer la faisabilite, la morbidite et le devenir de patientes ayant eu une exenteration pelvienne laparoscopique avec abord perineal. Patientes et methodes Depuis 2000, nous avons realise sept exenterations pelviennes laparoscopiques avec abord perineal associe a une reconstruction complexe. Toutes les patientes sauf une avaient recu une irradiation prealable. Une exenteration pelvienne totale a ete realisee dans deux cas, une exenteration anterieure et moyenne dans trois cas et dans deux cas une exenteration moyenne et posterieure. La reconstruction urinaire a ete realisee dans un cas par un Bricker, dans quatre cas par la confection d'une poche continente de Miami. Une reconstruction vaginale a ete effectuee dans trois cas par une epiplooplastie tubulisee, dans un cas par un lambeau musculocutane gluteal inferieur. Le retablissement de la continuite digestive a ete realise par une anastomose colorectale protegee. Une patiente a subi une colostomie definitive. Une conversion en minilaparotomie a ete necessaire dans un cas afin de realiser une radiotherapie peroperatoire. Resultats La duree operatoire est de 6 h 30 avec des saignements inferieurs a 500 cc. Quatre patientes ont eu une complication postoperatoire mineure. Aucune patiente n'a eu de revision de la poche de Miami. La duree d'hospitalisation est de 27 jours. Avec un suivi moyen de 14 mois, quatre patientes sont mortes, dont trois en raison d'une evolution metastatique. Une patiente presente une recidive locale. Deux patientes sont en vie sans recidive. Discussion et conclusion L'association de l'abord laparoscopique et perineal permet de realiser avec reproductibilite et faisabilite un geste complexe d'exenteration pelvienne associee a une reconstruction des trois axes (urinaire, genital et digestif).

La chirurgie oncoplastique du sein est une nouvelle procedure dans le traitement conservateur du sein. Il existe de nombreuses publications sur ce sujet mais les bonnes indications de cette technique restent floues. Au travers d’une revue de la litterature et de notre experience, nous avons repertorie ici les criteres intervenants dans le choix de l’indication de l’oncoplastie. Il nous a paru important auparavant, de rappeler ce qu’est l’oncoplastie ainsi que la problematique carcinologique qui l’entoure.

Las miomectomias mediante laparotomia estan indicadas esencialmente en mujeres en edad fertil que presentan miomas sintomaticos y que no pueden beneficiarse de un tratamiento quirurgico por via histeroscopica o laparoscopica. Estas intervenciones no se encuentran desprovistas del riesgo de complicaciones peroperatorias, principalmente perdidas sanguineas graves que requieren transfusion, y postoperatorias, entre las cuales se situan en primer lugar las adherencias. Cabe subrayar la importancia de un estudio preciso que permitira evaluar del mejor modo las ventajas e inconvenientes de este tipo de intervencion.

Resume Les myomectomies par laparotomie s'adressent essentiellement aux femmes en âge de procreer qui ont des myomes symptomatiques et qui ne peuvent beneficier d'un traitement chirurgical par voie hysteroscopique ou cœlioscopique. Ces interventions ne sont pas denuees de complications peroperatoires representees essentiellement par des pertes sanguines importantes necessitant une transfusion, et postoperatoires au premier rang desquelles se situent les adherences postoperatoires. C'est souligner l'importance d'un bilan precis qui permettra d'evaluer au mieux les benefices et inconvenients de ce type d'intervention.

Objective To compare the accuracy of rectal endoscopic ultrasonography (REU) and magnetic resonance imaging (MRI) for predicting rectal wall involvement in patients presenting histologically proven deeply infiltrating endometriosis (DIE). Methods This was a retrospective study of a continuous series of 81 patients presenting histologically proven DIE who underwent preoperative investigations using both REU and MRI. The sonographer and the radiologist, who were unaware of the clinical findings and patient history, but knew that DIE was suspected, were asked whether there was involvement of the digestive wall. Results Rectal DIE was confirmed histologically in 34 of the 81 (42%) patients. For the diagnosis of rectal involvement, sensitivity, specificity and positive and negative predictive value for REU were 97.1%, 89.4%, 86.8% and 97.7% and for MRI they were 76.5%, 97.9%, 96.3% and 85.2%. Conclusion The sensitivity and negative predictive value of REU were higher than those of MRI suggesting that REU performs better than MRI in the diagnosis of rectal involvement for patients presenting with DIE. Prospective studies with a large number of patients are needed in order to validate these preliminary results. Copyright © 2004 ISUOG. Published by John Wiley & Sons, Ltd.

Resume L’endometriose pelvienne profonde se manifeste essentiellement par une symptomatologie douloureuse, dominee par la dyspareunie profonde et une symptomatologie fonctionnelle douloureuse a recrudescence menstruelle dont la semiologie est directement correlee a la localisation des lesions (vessie, rectum). Le bilan d’extension est essentiel pour faire la cartographie exacte des lesions d’endometriose profonde qui seule permettra une exerese complete. Le traitement de premiere intention reste chirurgical, les traitements medicaux n’etant dans la majorite des cas que palliatifs. Le succes therapeutique depend de la radicalite de l’exerese chirurgicale. L’analyse de la distribution anatomique des lesions d’endometriose pelvienne profonde permet de proposer une « classification chirurgicale » dans le but de codifier les modalites du traitement chirurgical. Des etudes complementaires sont necessaires pour preciser en pre- et en postoperatoire la place et les modalites des traitements medicaux.

Complication and survival analysis of cytoreduction surgery with modified posterior pelvic exenteration in the surgical treatment of the ovarian malignant tumor.A retrospective monocentric study between 2000 and 2013 in Rhone-Alpes cancer treatment center. One hundred and fifty-two patients with ovarian cancer and treated by surgery with modified posterior pelvic exenteration were included. Complication in the 30 days after surgery was analysed by the Clavien-Dindo classification.In our study, rate of global complication was 62.5% with a morbidity rate of grave complication of 7.9%. Our rate of complete resection was 82.2%. Three fistulas (2.2%) were found. On average, there was 6.6±1.8 (2-11) surgery gesture associated with Hudson resection during surgery. In univariate analysis, there was a statistic significant association between complication from the rank II of Clavien-Dindo classification and supraradical surgery, post-chemotherapy surgery, recurrent surgery, the resection of a diaphragmatic dome, and the partial gastric resection. This association was also observed with the number of surgical gesture associated with Hudson resection.The main prognostic surgical factor in ovarian cancer is to obtain a no macroscopic residual disease. The modified posterior pelvic exenteration allowed to obtain it. Our study demonstrates a low rate of grave complication further to this type of surgery.

The objective of this study was to evaluate outpatient satisfaction for breast cancer surgery and compare with inpatient satisfaction.Our observational prospective study included all patients who underwent breast cancer surgical procedure (breast-conserving surgery and sentinel node biopsy) between July and December 2013 in a cancer center. Patients were asked to answer a questionnaire at discharge and 30 days after surgery.One hundred and fifty-five patients (exclusively women) were included; the outpatient group comprised 102 patients and the inpatient group 53. The study showed no statistical difference in patients' satisfaction betweeen the two groups at discharge (P=0.20) and 30 days after surgery (P=0.30); 101 (99%) outpatients and 44 (95.7%) inpatients had very good or excellent level of satisfaction at discharge and 88 (92,7%) and 49 (98%), respectively 30 days after surgery. The overall mean satisfaction score was 9.1±1.2 [3-10] at discharge and 8.7±1.3 [3-10] 30 days after surgery.Our study found high degree of satisfaction after breast surgery for cancer both for outpatients and inpatients. This suggests that ambulatory surgery is possible and valid for this type of oncologic breast surgery.

We report two cases of spontaneous regression of breast cancer occurred in our institution. It was about a 34- and an 82-year-old patient. The examination revealed a palpable nodule. In both cases, biopsy revealed a negative immunohistochemical staining for estrogen and progesterone receptors, and HER-2 negative. Histological analysis of the surgical specimen found fibrous tissue rearrangement without carcinoma. In the first case, a sarcoidosis was diagnosed at the same time, the mediastinal nodes mimicked a metastatic cancer. These cases illustrate a rare phenomenon. The main hypothesis is a carcinoma- directed immune response triggered by the biopsy.

La conisation et la trachelectomie elargie, plus ou moins associees au curage pelvien, constituent les traitements conservateurs dans les cancers du col uterin.

The biphasic waveform (BPW) is an abnormality of the optical transmission waveform obtained during measurement of the activated partial thromboplastin time on a specific photometric haemostasis autoanalyzer. This abnormality is related to calcium-dependent formation of complexes between C reactive protein and very low density lipoprotein. Biphasic waveform had a high sensitivity and negative predictive value for the identification of patients with severe sepsis and septic shock. On day 3, the time course of the biphasic waveform is a marker for the prognosis of sepsis-related mortality. The BPW is not a surrogate marker for C-reactive protein or procalcitonin and provides additional information. Further trials should be necessary using BPW for diagnostic and management procedures. Compared with other laboratory markers such as C reactive protein or procalcitonin, activated partial thromboplastin time waveform analysis is a tool that is rapid, inexpensive, effective and available 24 hours a day. When the analyzer is locally available, waveform analysis of this routine coagulation test provides information for the diagnosis of severe sepsis and the prognosis of septic patients.

To compare the accuracy of rectal endoscopic ultrasonography (REU) and magnetic resonance imaging (MRI) for predicting rectal wall involvement in patients presenting histologically proven deeply infiltrating endometriosis (DIE).This was a retrospective study of a continuous series of 81 patients presenting histologically proven DIE who underwent preoperative investigations using both REU and MRI. The sonographer and the radiologist, who were unaware of the clinical findings and patient history, but knew that DIE was suspected, were asked whether there was involvement of the digestive wall.Rectal DIE was confirmed histologically in 34 of the 81 (42%) patients. For the diagnosis of rectal involvement, sensitivity, specificity and positive and negative predictive value for REU were 97.1%, 89.4%, 86.8% and 97.7% and for MRI they were 76.5%, 97.9%, 96.3% and 85.2%.The sensitivity and negative predictive value of REU were higher than those of MRI suggesting that REU performs better than MRI in the diagnosis of rectal involvement for patients presenting with DIE. Prospective studies with a large number of patients are needed in order to validate these preliminary results.

Verrucous carcinoma is a rare form of vulvar squamous carcinoma, with particular clinical presentation and histological description. We analyze the specificity of the treatment of this form.We analyzed the records of 8 patients treated in our hospital between 1995 and 2001. In the absence of an associated lesion, the treatment was partial vulvectomy without lymph node dissection. A close follow-up was then organized.Mean age was 76 years (range 54 to 92). In 7 out of the 8 cases we found an associated lesion: invasive squamous carcinoma, VIN III or lichen. Two patients later developed a squamous carcinoma. Two others died because of intercurrent diseases. The last four patients are doing well.We confirm the efficacy of the treatment generally proposed: partial vulvectomy, without lymph node dissection and without complementary treatment but with a close follow-up. The coexistence of other vulvar lesions such as lichen is remarkable in our series.

Deep pelvic endometriosis presents essentially in the form of a painful syndrome dominated by deep dyspareunia and painful functional symptoms that recur according to the menstrual cycle, with the semiology directly correlated with the location of the lesions (bladder, rectum). It is essential to investigate these deep endometriosis lesions and draw up a precise map, which is the only way to be sure that exeresis will be complete. The treatment of first intention remains surgery, and medical treatment is only palliative in the majority of cases. Success of treatment depends on how radical surgical exeresis is. Based on analysis of the anatomical distribution of deep pelvic endometriosis lesions, a "surgical classification" is proposed with the aim of establishing standard modes for surgical treatment. Further studies are required to clarify the place and modes for pre- and postoperative medical treatment.

Scar endometriosis is a rare disease which is difficult to diagnose. The symptoms are nonspecific, typically involving abdominal wall pain at the time of menstruation. Clinical examination may reveal a painful nodule, if the scar involved is located on the abdominal wall, but is normal, when the lesion is located on the uterine scar. Other means of investigation (transvaginal ultrasonography, computed tomography) may be useful in case of lesions on the abdominal wall, or if the nodule is large, but give no specific results. The diagnosis is frequently made only after excision of the lesion. We report here 4 patients operated for scar endometriosis (two abdominal and two uterine scars) for whom MRI had suggested the diagnosis. Thanks to its very high spatial resolution, MRI enables very small lesions to be detected and can distinguish the hemorrhagic signal of endometriotic lesions. Furthermore, it performs better than the CT scan in detecting the limits between muscles and abdominal subcutaneous tissues.

The aim of this study was to determine the metrological parameters of a french version of the Pleasure Scale for Children (PSC): 214 (121 males and 93 females) with a mean age of 8.69 years (sd: 1.95) ranging from 6 years to 12 years were included in the study. The children were inpatients presenting various somatic disorders.First a principal component analysis was done on the 39 items of the correlation matrix. Several guidelines were used to limit the number of factors (Kaiser criteria, Cattell scree test, Horn parallel analysis). Secondly the construct validity was studied using the alpha Cronbach coefficient and by calculing the Pearson correlation coefficient between each item and the total score. Thirdly the concurrent validity was determinated using two items of the Children Depression Rating Scale--Revised (CDRS-R) measuring pleasure (social withdrawal and enjoyment capacity). Fourthly the discriminant validity of the PSC was studied by comparing non depressive children (score lower than 30 to the CDRS-R) and depressive children (score higher than 30 to the CDRS-R).The principal component analysis showed a one factor solution with 33 items among the 39 having a higher than 0.3 saturation. The Cronbach alpha coefficient was 0.84. All the items correlated with the total score. The mean value was 0.37. The correlations between the total score of the scale and the CDRS-R enjoyment capacity and social withdrawal items were respectively -0.37 (p0.01) and -0.38 (p0.01). PSC score were significantly lower in depressive children (m = 86.96; sd = 8.33) than in non depressive children (m = 94.67; sd = 10) (t = 5.32; df = 212; p0.001).

In this retrospective study, the major complication rates that occurred during the preparatory phase of laparoscopic surgery were compared according to procedure. The first operating team habitually used a classic approach to laparoscopy and created the pneumoperitoneum before introduction of the optic trocar. A second team, located at another hospital, always performed "open" laparoscopy that involved layer-by-layer dissection into the abdominal cavity enabling visual placement of the trocar. A retrospective review of the medical records of patients who underwent laparoscopy performed by each of these 2 teams was conducted to determine the complication rate in each group. A total of 8324 patients underwent laparoscopy using the classic technique. All laparoscopies in this group were completed successfully. There were 4 complications identified (0.05%), including 1 vascular injury and 3 bowel injuries. The vascular injury and 2 bowel injuries were recognized immediately and repaired during the operation. The fourth, a bowel injury resulting from insertion of the pneumoperitoneum needle, was not recognized until peritonitis developed postoperatively. Treatment by laparotomy was successful. There were 1562 patients in the group who had open laparoscopy. Three of these procedures had to be converted to laparotomy, 1 in a morbidly obese woman and 2 in patients who had several prior abdominal surgeries. Three major complications (0.19%) occurred in this group. Two were bowel injuries that were recognized and treated immediately. Thirty days after surgery, the third patient developed a small bowel obstruction at the site of the umbilical trocar. Bowel resection was performed.

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The usefulness of a nephelometric-based serum myoglobin assay kit in the early diagnosis of acute myocardial infarction was assessed in 92 consecutive patients admitted within 24 hours of the onset of spontaneous chest pain lastingor = 20 minutes. The discharge diagnosis was acute myocardial infarction in 37 patients (40.2%), myocardial infarction lastingor = 6 hours in 10, and no myocardial infarction in 45 (48.9%). The characteristic curve showed that the best differential diagnostic value was a serum myoglobinor = 130 micrograms/l (sensitivity, 75.6%; specificity, 91.7%; positive-predictive value, 88%; negative-predictive value, 82%). The initial diagnosis was doubtful in 33 patients (36%) because of an inconclusive electrocardiogram. A serum myoglobin value ofor = 130 micrograms/l would have identified 9 of the 13 patients with acute myocardial infarction and all of the 20 patients without myocardial infarction, giving an accuracy of 84.8%. These results suggest that this new rapid, quantitative serum myoglobin assay would be useful in the evaluation of suspected myocardial infarction, especially in patients with an inconclusive electrocardiogram.

Objectifs Definir un protocole IRM adapte au bilan d’extension des cancers du col uterin. Illustrer la correspondance en IRM des stades de la classification FIGO. Connaitre les performances de l’IRM dans l’evaluation des principaux facteurs pronostiques qui conditionnent l’attitude therapeutique. Montrer son role dans le suivi post-therapeutique. Points cles L’IRM est la technique d’imagerie la plus fiable dans le bilan d’extension des cancers du col uterin, notamment grâce aux sequences T2. Les principaux facteurs pronostiques et enjeux de l’imagerie sont les extensions parametriale et ganglionnaire. Le suivi post-therapeutique en IRM permet de detecter des reliquats ou des recidives.

Resume Parmi les divers facteurs qui interferent dans la physiopathologie de l'asthme infantile, le role d'un phenotype heterozygote de l'alpha-1-antitrypsine pouvait etre evoque. La comparaison des phenotypes Pi de 110 enfants asthmatiques hospitalises et de 100 temoins ne montre pas de differences significatives dans la distribution des phenotypes Pi M et non -M. Il en est de meme lorsqu'on compare les phenotypes des 48 enfants atteints d'un asthme severe, a ceux des 52 enfants atteints d'un asthme modere ou benin. Cette etude ne demontre donc pas le role eventuel du phenotype Pi, ni sur le declenchement de l'asthme infantile, ni sur sa gravite. Mais elle ne peut en rien prejuger d'une influence du phenotype Pi heterozygote sur l'evolution a long terme de la maladie.

Summary In a previous study, we have showed a great heterogeneity of antitetanous antibodies using polyacrylamide thin layer isoelectrofocusing. In this study, we have improved the resolution of the focused antitetanous antibodies by electrofocusing in sucrose density gradients, which is a suitable procedure for preparative work. After isoelectrofocusing the elution is performed according to any pH variation. For each fraction, we have determined pH, absorbance at 280 nm, protein level by method of Lowry, IgG concentration using immunonephelometric method and antitetanous antibodies concentration by radioimmunoassay. Furthermore, the purity of each fraction is verified by polyacrylamide slab gel isoelectrofocusing. It is concluded that the isoelectric point of antitetanous antibodies is alkaline range between 7.5 and 8.5. This precise knowledge could afford an opportunity for the industrial preparation of antitetanous antibodies.

A study was done of 15 children and adolescents, aged 2.5 to 17.5 years, who were treated by continuous ambulatory peritoneal dialysis (CAPD) for 6 to 24 months. Plasma albumin concentration decreased from 34.4 +/- 4.8 g/liter at the onset of therapy to 31.3 +/- 5.3 g/liter after 19 to 24 months. Children less than 6 years old had lower albumin levels (29.4 +/- 1.7 g/liter) than did the older group (36.3 +/- 4.2 g/liter). The lower plasma albumin was related to peritoneal protein loss but not to protein intake. Plasma free amino acid concentrations were not significantly modified. No changes occurred in the oral glucose tolerance test during the course of CAPD. Plasma cholesterol and triglycerides were abnormally high for age, with a correlation seen between cholesterolemia and peritoneal protein loss.

The BB fraction of serum creatine kinase was estimated in 3 groups of newborn : 30 healthy newborn at term, 20 newborn ill but without cerebral distress, 17 newborn with acute perinatal or foetal distress. In the first two groups, BB fraction was negligeable or nil, in respectively 26 and 16 cases, and between 1 and 4% in 4 cases. In the third group, it was greater than 4% in 10 cases, nil in 6 and 4% in one. The lability of this isoenzyme over periods of time, and in relation to temperature, requires the use of clearly defined techniques of sampling, storage and estimation, which may explain the false negatives seen. The determination of this isoenzyme, virtually exclusively cerebral, would thus appear to be a reliable biological indicator of neonatal cerebral distress.