What every radiologist should know about adnexal torsion.

Adnexal torsion is the fifth most common gynecologic surgical emergency, requiring clinician and radiologist awareness. It involves the rotation of the ovarian tissue on its vascular pedicle leading to stromal edema, hemorrhagic infarction, and necrosis of the adnexal structures with the subsequent sequelae. Expedient diagnosis poses a difficult challenge because the clinical presentation is variable and often misleading. Adnexal torsion can mimic malignancy as it can take a subacute, intermittent, or chronic course, and thereby can be complicated to diagnose. The torsion may occur in the normal ovary but is usually secondary to a preexisting adnexal mass. Early surgery is necessary to avoid irreversible adnexal damage and to preserve ovarian function especially in children and young women. Pelvic ultrasound forms the foundation of diagnostic evaluation due to its ability to directly and rapidly evaluate both ovarian anatomy and perfusion. Moreover, it is a noninvasive and accessible technique. However, the color Doppler appearance of the ovary should not be relied upon to rule out torsion because a torsed ovary or adnexa may still have preserved arterial flow due to the dual blood supply. MR and CT may be used as problem-solving tools needed after the ultrasound examination but should not be the first-line imaging modalities in this setting due to ionizing radiation and potential time delay in diagnosis. The goal of this article is to review the adnexal anatomy, to familiarize radiologists with the main imaging features, and to discuss the main mimickers and the most common pitfalls of adnexal torsion. Main points Adnexal torsion is an uncommon gynecological disorder caused by partial or complete rotation of the ovary and/or the Fallopian tube about the infundibulopelvic ligament. The ovaries receive a dual blood supply from the ovarian artery and uterine artery. The lack of pathognomonic symptoms and specific findings on physical examination makes this entity difficult to diagnose. Since the right adnexa are most commonly involved, symptoms may mimic acute appendicitis. Persistence of adnexal vascularization does not exclude torsion. In the pediatric age group, gray-scale ultrasound is the best modality of choice. Obtaining CT and/or MR images should not delay treatment in order to preserve ovarian viability.

Preoperative clinical pathway of breast cancer patients: determinants of compliance with EUSOMA quality indicators.

BACKGROUND: The European Society of Breast Cancer Specialists (EUSOMA) has defined quality indicators for breast cancer (BC). The aim of this study was to describe the preoperative clinical pathway of breast cancer patients and evaluate the determinants of compliance with EUSOMA quality indicators in the Optisoins01 cohort. METHODS: Optisoins01 is a prospective, multicentric study. Data from operable BC patients were collected, including results from before surgery to 1 year follow-up. Seven preoperative EUSOMA quality indicators were compared with the clinical pathways Optisoins01. RESULTS: Six hundred and four patients were included. European Society of Breast Cancer Specialists targets were reached for indicator 1 (completeness of clinical and imaging diagnostic work-up), 3 (preoperative definitive diagnosis) and 5 (waiting time). For indicator 8 (multidisciplinary discussion), the minimum standard of 90% of the patients was reached only in general hospitals and comprehensive cancer centres. Having more than 1 medical examination within the centre was associated with an increased waiting time for surgery, whereas it was reduced by having an outpatient breast biopsy. The comprehensive cancer centre type was the only parameter associated with the other quality indicators. CONCLUSIONS: European Society of Breast Cancer Specialists quality indicators are a useful tool to evaluate care organisations. This study highlights the need for a standardised and coordinated preoperative clinical pathway.

The patient-breast cancer care pathway: how could it be optimized?

BACKGROUND: A care pathway is defined as patient-focused global care that addresses temporal (effective and coordinated management throughout the illness) and spatial issues (treatment is provided near the health territory in or around the patient's home). Heterogeneity of the care pathways in breast cancer (BC) is presumed but not well evaluated. The OPTISOINS01 study aims to assess every aspect of the care pathway for early BC patients using a temporal and spatial scope. METHODS/DESIGN: An observational, prospective, multicenter study in a regional health territory (Ile-de-France, France) in different types of structures: university or local hospitals and comprehensive cancer centers. We will include and follow during 1 year 1,000 patients. The study consists of 3 work-packages: - Cost of pathway The aim of this WP is to calculate the overall costs of the early BC pathway at 1 year from different perspectives (society, health insurance and patient) using a cost-of-illness analysis. Using a bottom-up method, we will assess direct costs, including medical direct costs and nonmedical direct costs (transportation, home modifications, home care services, and social services), and indirect costs (loss of production). - Patient satisfaction and work reintegration Three questionnaires will assess the patients' satisfaction and possible return to work: the occupational questionnaire for employed women; the questionnaire on the need for supportive care, SCNS-SF34 ('breast cancer' module, SCNS-BR8); and the OUTPASSAT-35 questionnaire. - Quality, coordination and access to innovation Quality will be evaluated based on visits and treatment within a set period, whether the setting offers a multidisciplinary consultative framework, the management by nurse coordinators, the use of a personalized care plan, the provision of information via documents about treatments and the provision of supportive care. The coordination between structures and caregivers will be evaluated at several levels. Day surgery, home hospitalization and one-stop breast clinic visits will be recorded to assess the patient's access to innovation. DISCUSSION: The assessment of care pathways encourages the implementation of new payment models. Our approach could help health care professionals and policymakers to establish other cost-of-illness studies and plan the allocation of resources on a patient basis rather than a visit basis.

[Menometrorrhagia]. / Une prise en charge qui répond à un algorithme précis. Ménométrorragies.

Menometrorrhagia is a frequent cause of medical consulting. After exclusion of pregnancy, main aetiologies are the uterine (polyp, myoma, adenomyosis, cancer) or adnexial abnormality (ovarian cyst or cancer), the disorders of hemostasis (Willebrand...), the dysfunctional uterine bleeding. A clinical examination is necessary to provide an accurate diagnosis and find complications such as anaemia. Pelvic ultrasound examination and endometrial biopsy are required to eliminate endometrial cancer. The treatment of menometrorrhagia consists of symptomatic treatment (tranexamic acid, levonorgestrel intrauterine device) and specific treatment of its cause (hysteroscopic resection of myom, polyp, endometrectomy, hysterectomy).

[Diagnosis of cervical and endometrial cancer]. / Diagnostic des cancers du col de l'utérus et de l'endomètre.

Updated French guidelines for clinical practice have been published by the National Cancer Institute in 2010, concerning the diagnosis and the treatment of cervix and endometrial cancers. The diagnosis of cervix cancer, suspected when a cervix tumour is observed in a patient presenting with vaginal bleeding, especially in women with risk factors (previous cervix dysplasia, HIV infection, tobacco use). The diagnosis is confirmed by pathology of cervix biopsy (macroscopic cervix tumour or microscopic lesions detected by screening). The diagnosis of endometrial cancer should be evoked in post-menopausal women presenting with vaginal bleeding, especially in high risk populations (obese, long exposure to estrogens). The diagnosis is based on histologic examination of endometrial biopsy. The assessment of pelvic extension must include clinical examination and pelvic and lombo-aortic MRI imaging.

Combined conservative surgical and medical treatment of a uterocutaneous fistula.

Uterocutaneous fistula is a rare complication that may follow cesarean section. Herein is described a rare case of uterocutaneous fistula. The patient, a 28-year-old woman with a history of American Society for Reproductive Medicine stage IV endometriosis (Douglas pouch obliteration), underwent a cesarean section at 25 weeks of gestation (twin pregnancy). Postoperatively, the patient returned to the emergency service because of the appearance of pus through the cesarean section abdominal scar, and was treated for a subcutaneous abscess. Because drainage continued, the presence of a uterocutaneous fistula was suspected. Magnetic resonance imaging confirmed this diagnosis. Hysteroscopy clearly revealed the uterine neck of the fistula tract. Leuprolide acetate (gonadotropin-releasing hormone agonist) deposit suspension was administered subcutaneously monthly for 6 months. Surgery via laparoscopy and laparotomy was performed. This combined medical and conservative surgical treatment was successful. At 6-month follow-up, hysteroscopy revealed a normal uterine cavity. We conclude that magnetic resonance imaging and hysteroscopy are helpful in diagnosis of uterocutaneous fistula. Conservative surgical treatment associated with medical therapy can be an efficient procedure in women who desire subsequent pregnancies.

Direct medical and non-medical costs of a one-year care pathway for early operable breast cancer: Results of a French multicenter prospective study.

INTRODUCTION: The organization of health care for breast cancer (BC) constitutes a public health challenge to ensure quality of care, while also controlling expenditure. Few studies have assessed the global care pathway of early BC patients, including a description of direct medical costs and their determinants. The aims of this multicenter prospective study were to describe care pathways of BC patients in a geographic territory and to calculate the global direct costs of early stage BC during the first year following diagnosis. METHODS: OPTISOINS01 was a multicenter, prospective, observational study including early BC patients from diagnosis to one-year follow-up. Direct medical costs (in-hospital and out-of-hospital costs, supportive care costs) and direct non-medical costs (transportation and sick leave costs) were calculated by using a cost-of-illness analysis based on a bottom-up approach. Resources consumed were recorded in situ for each patient, using a prospective direct observation method. RESULTS: Data from 604 patients were analyzed. Median direct medical costs of 1 year of management after diagnosis in operable BC patients were €12,250. Factors independently associated with higher direct medical costs were: diagnosis on the basis of clinical signs, invasive cancer, lymph node involvement and conventional hospitalization for surgery. Median sick leave costs were €8,841 per patient and per year. Chemotherapy was an independent determinant of sick leave costs (€3,687/patient/year without chemotherapy versus €10,706 with chemotherapy). Forty percent (n = 242) of patients declared additional personal expenditure of €614/patient/year. No drivers of these costs were identified. CONCLUSION: Initial stage of disease and the treatments administered were the main drivers of direct medical costs. Direct non-medical costs essentially consisted of sick leave costs, accounting for one-half of direct medical costs for working patients. Out-of-pocket expenditure had a limited impact on the household.

Fertility and pregnancy outcomes following uterine devascularization for severe postpartum haemorrhage.

BACKGROUND: To evaluate the fertility and pregnancy outcomes following uterine devascularization for postpartum haemorrhage (PPH). METHODS: All patients who required uterine devascularization, i.e. bilateral uterine artery ligation (Group A), and either bilateral utero-ovarian ligament (Group B) or suspensory ligament of ovary ligation (Group C) in cases of persistent haemorrhage, for PPH with no concomitant procedures from December 1997 to March 2004 were included. Data were retrieved from medical files and telephone interviews. RESULTS: Data were available for 32 of the 40 (80%) patients included in the study. All patients but 4 had a return to normal menses. Postpartum amenorrhea was secondary to ovarian failure in two cases, and synechiae or necrotic uterus each in one case. These four patients belonged to Group C, whereas no adverse events were observed in groups A and B. Thirteen patients had 16 pregnancies with 13 term deliveries, 1 ectopic pregnancy and 2 abortions. Clinical course of the 13 complete gestations were uneventful but PPH recurred in 4 (31%) due to placenta accreta in three cases. CONCLUSIONS: Uterine artery ligation, whether or not associated with utero-ovarian ligament ligation, for PPH does not appear to compromise the patients' subsequent fertility and obstetrical outcome.

Doxorubicin and ifosfamide for high-grade sarcoma during pregnancy.

PURPOSE: Doxorubicin and ifosfamide are highly active drugs for the treatment of high-grade sarcomas, but little is known on the optimal management of young patients who develop such malignancies during pregnancy. METHODS: We report on a single-institution series of patients (n = 9) with high-grade sarcoma diagnosed during the third trimester of pregnancy. Neoadjuvant chemotherapy combining doxorubicin (50 mg/m(2) day 1) and ifosfamide (2.5 g/m(2) days 1-2) with standard mesna rescue every 3 weeks was administered during the third trimester of pregnancy in five patients. RESULTS: We observed a favourable outcome for both the mother and the offspring in all cases. Maternal and neonatal pharmacokinetic data for ifosfamide were obtained from one patient and did not evidence a transplacental transfer of this drug. The use of other active drugs (cisplatin, etoposide, dactinomycin and cyclophosphamide) in sarcoma during pregnancy is discussed on the basis of a comprehensive review of the English literature. CONCLUSIONS: In view of this single-centre experience, we suggest that the treatment of high-grade sarcoma during the third trimester of pregnancy should include an adapted regimen tailored to the pharmacological specificities of the pregnant patients.

Surgical reduction of hypertrophy of the labia minora.

OBJECTIVE: To evaluate postoperative satisfaction, including improvements in quality of life, among patients who had undergone labia minora reduction. METHODS: In a retrospective descriptive study, women who had undergone labiaplasty for hypertrophy of the labia minora between January 2005 and December 2009 were contacted by telephone. The women were asked to answer a satisfaction survey evaluating the esthetic and functional results of the surgery. RESULTS: Among 21 patients who had labiaplasty using either a pedicle flap reconstruction (n=18, 86%) or a nymphectomy technique (n=3, 14%), 18 (86%) were contacted successfully and took part in the survey. All of the contacted patients were satisfied with the overall outcome of the surgery, with a mean rating of 8.7 out of 10 at a median follow-up of 17 months (interquartile range 6-25 months). From an esthetic point of view, all 18 patients reported an improvement in comfort with respect to any form of original functional discomfort. Concerning sexuality, 95% of the sexually active patients had originally described some form of physical or psychologic discomfort, and all of them reported total disappearance of this symptomatology. CONCLUSION: Labiaplasty provided overall satisfaction in terms of improvements in patient quality of life and sexuality.

Fertility after B-Lynch suture and stepwise uterine devascularization.

OBJECTIVE: To report the obstetric outcome in a patient who had previously undergone a stepwise uterine devascularization followed by a B-Lynch suture for severe postpartum hemorrhage (PPH). DESIGN: Case report. SETTING: University hospital. PATIENT(S): A 29-year-old woman whose first pregnancy was complicated by severe PPH due to uterine atony. INTERVENTION(S): Stepwise uterine devascularization followed by a B-Lynch suture because of persistent PPH. MAIN OUTCOME MEASURE(S): Preservation of reproductive capacity. RESULT(S): Two years later, the patient conceived spontaneously and delivered a healthy infant by caesarean section after an uneventful pregnancy. During the operation, the uterus showed no marks of the former B-Lynch suture. CONCLUSION(S): This is the first reported case of obstetric outcome after stepwise uterine devascularization and B-Lynch suture. Further case series with mid- and long-term follow-up are required to determine whether the B-Lynch suture has an impact on the patient's subsequent fertility and pregnancies and to establish its place in the PPH surgical management algorithm.