Long-term oncological safety of sentinel lymph node biopsy in early-stage cervical cancer: A post-hoc analysis of SENTICOL I and SENTICOL II cohorts.

OBJECTIVES: To compare oncologic outcomes of patients with early-stage cervical cancer and negative nodes who underwent sentinel lymph node biopsy alone (SLNB) versus pelvic lymphadenectomy (PL). METHODS: An ancillary analysis of two prospective multicentric trials on SLN biopsy for cervical cancer (SENTICOL I and II) was conducted. Only patients with early-stage cervical cancer (IA to IIA FIGO stage), bilateral detection of SLN, negative SLN after ultrastaging and negative non-SLN after final pathologic examination were included. Risk-factors of recurrence and disease-specific mortality were determined by Cox proportional hazard models. RESULTS: Between January 2005 and July 2012, 259 node-negative patients were analyzed: 87 in the SLNB group and 172 in the PL group. The median follow-up was 47 months [4-127]. During the follow-up, 21 patients (8.1%) experienced recurrences, including 4 nodal recurrences (1.9%), and 9 patients (3.5%) died of cervical cancer. Disease-free survival (DFS) and disease-specific survival (DSS) were similar between SLNB and PL groups, 85.1% vs. 80.4%, p = 0.24 and 90.8% vs. 97.2%, p = 0.22 respectively. By Cox multivariate analysis, SLNB compared to PL was not associated with DFS (HR = 1.78, 95%CI = [0.71-4.46], p = 0.22) neither with DSS (HR = 3.02, 95%CI = [0.69-13.18], p = 0.14). Only pathologic risk level according to the Sedlis criteria was an independent predictor of DFS and DSS. CONCLUSIONS: Omitting full pelvic lymphadenectomy for patients with bilateral negative SLN does not seem to be associated with an increased risk of recurrence in this series. Survival non-inferiority needs to be confirmed by prospective trials.

Intraoperative Factors that Predict the Successful Placement of Essure Microinserts.

STUDY OBJECTIVE: To determine whether the number of coils visualized in the uterotubal junction at the end of hysteroscopic microinsert placement predicts successful tubal occlusion. DESIGN: Cohort retrospective study (Canadian Task Force classification II-2). SETTING: Department of obstetrics and gynecology in a teaching hospital. PATIENTS: One hundred fifty-three women underwent tubal microinsert placement for permanent birth control from 2010 through 2014. The local institutional review board approved this study. INTERVENTION: Three-dimensional transvaginal ultrasound (3D TVU) was routinely performed 3 months after hysteroscopic microinsert placement to check position in the fallopian tube. MEASUREMENTS AND MAIN RESULTS: The correlation between the number of coils visible at the uterotubal junction at the end of the hysteroscopic microinsert placement procedure and the device position on the 3-month follow-up 3D TVU in 141 patients was evaluated. The analysis included 276 microinserts placed during hysteroscopy. The median number of coils visible after the hysteroscopic procedure was 4 (interquartile range, 3-5). Devices for 30 patients (21.3%) were incorrectly positioned according to the 3-month follow-up 3D TVU, and hysterosalpingography was recommended. In those patients the median number of coils was in both the right (interquartile range, 2-4) and left (interquartile range, 1-3) uterotubal junctions. The number of coils visible at the uterotubal junction at the end of the placement procedure was the only factor that predicted whether the microinsert was well positioned at the 3-month 3D TVU confirmation (odds ratio, .44; 95% confidence interval, .28-.63). When 5 or more coils were visible, no incorrectly placed microinsert could be seen on the follow-up 3D TVU; the negative predictive value was 100%. No pregnancies were reported. CONCLUSION: The number of coils observed at the uterotubal junction at the time of microinsert placement should be considered a significant predictive factor of accurate and successful microinsert placement.

Sentinel node biopsy for the management of early stage endometrial cancer: long-term results of the SENTI-ENDO study.

OBJECTIVE: We report the long-term results of the SENTI-ENDO study evaluating the impact of sentinel lymph node (SLN) biopsy on management and survival in patients with early stages of endometrial cancer (EC). METHODS: Patients with FIGO stage I-II EC underwent pelvic SLN biopsy after cervical dual injection (technetium and patent blue) and systematic pelvic node dissection. This study is a secondary endpoint reporting the long-term recurrence free survival (RFS) and the impact of the SLN procedure on adjuvant therapies. RESULTS: The median follow-up was 50 months (range: 3-77 months). Eighteen of the 125 patients (14.4%) experienced a recurrence. The 50-month recurrence-free survival (RFS) was 84.7% with no difference between patients with and without detected SLN (p = 0.09). Among patients with detected SLN (111), no difference in RFS was observed between those with and without positive SLN (p = 0.5). In the whole population, adjuvant therapy was performed in low-, intermediate- and high-risk groups in 31 of 64 patients (48.4%), 28 of 37 patients (75.7%) and 14 of 17 patients (82.3%), respectively (p = 0.0001). For the 111 patients with detected SLN, EBRT was performed in 27 of the 89 with negative SLN and in 11 of the 14 with positive SLN (p = 0.001). Chemotherapy was performed more frequently in patients with positive SLN (6/12, 50%) than in patients with negative SLN (7/56, 12.5%) (p = 0.009). CONCLUSIONS: Our results support the impact of SLN biopsy on surgical management and indications for adjuvant therapies. Further studies are required to assess the clinical impact of the SLN biopsy in early stage EC.

Contribution of lymphoscintigraphy to intraoperative sentinel lymph node detection in early cervical cancer: Analysis of the prospective multicenter SENTICOL cohort.

PURPOSE: To evaluate the contribution of preoperative lymphoscintigraphy to intraoperative lymphatic mapping (ILM) in early cervical cancer METHODS: We conducted an ancillary analysis of the multicenter prospective SENTICOL study in early cervical cancer. Radiocolloid was injected intracervically on the day before (long protocol) or morning of (short protocol) surgery, lymphoscintigraphy was performed, and the results of a centralized image review were communicated to the surgeons. ILM was performed on combined radioactivity/patent blue detection. Sentinel lymph nodes (SLNs) were electively sampled before routine bilateral pelvic lymphadenectomy by laparoscopy. RESULTS: Of 139 patients in the modified intention-to-diagnose analysis, 114 had centrally reviewed lymphoscintigrams, which showed 352 SLNs in 100 patients. Lymphoscintigraphy and ILM detection rates were 87.8% and 97.8%, respectively. Agreement between lymphoscintigraphy and ILM was low for the number of SLNs (κ=0.23; -0.04; 0.49) and bilateral SLNs (κ=0.36; 0.2; 0.52). No patient without SLNs by ILM had SLNs by lymphoscintigraphy. Lymphoscintigraphy identified substantial proportions of unusual drainage pathways. No patients with metastatic nodes had SLNs by lymphoscintigraphy but not by ILM in the relevant territory. In 1 of the 2 patients with false-negative SLN results, SLNs were bilateral by lymphoscintigraphy and unilateral by ILM. CONCLUSION: Although the detection rate was lower by lymphoscintigraphy than by ILM, the substantial proportions of SLNs in unusual territories provided valuable guidance for the surgical exploration. Awareness of the limited agreement between lymphoscintigraphic and surgical detection might help surgeons decrease the false-negative rate.

Risk of incidental finding of endometrial cancer at the time of hysterectomy for benign condition.

STUDY OBJECTIVE: To assess the risk of unanticipated endometrial carcinoma during hysterectomy to treat a presumed benign condition. DESIGN: Retrospective analysis (Canadian Task Force classification II-2). SETTING: Tertiary referral center, university hospital. PATIENTS: All women who underwent hysterectomy to treat presumed benign indications at our center from January 2000 to December 2011 were identified. We analyzed all pathologic reports and identified cases of unexpected endometrial carcinoma. INTERVENTIONS: Hysterectomy by any approach to treat presumed benign indications. MEASUREMENTS AND MAIN RESULTS: At our institution, 2179 hysterectomies were performed to treat presumed benign indications. Nine (0.4%) revealed unexpected endometrial carcinoma (95% confidence interval, 0.2-0.7). CONCLUSION: Our data suggest that the rate of unanticipated endometrial carcinoma during hysterectomy to treat benign conditions is low.

The sentinel node technique detects unexpected drainage pathways and allows nodal ultrastaging in early cervical cancer: insights from the multicenter prospective SENTICOL study.

BACKGROUND: Sentinel lymph node (SLN) biopsy may improve nodal staging in cervical cancer. The aims of this study are to determine the rate of unusual patterns of cervical lymphatic drainage, to determine the rates of micrometastases and isolated tumor cells (ITCs) in SLNs, and to assess the clinical impact of SLN biopsy. METHODS: Multicenter prospective study conducted between January 2005 and June 2007 in women undergoing laparoscopic surgery for early cervical cancer. Combined technetium/Patent Blue labeling was used. Lymphoscintigraphy was performed before surgery. SLN location was recorded, and factors associated with location were explored. SLNs underwent step sectioning ± immunohistochemistry. RESULTS: 145 patients were enrolled and 139 included in a modified intention-to-diagnose analysis. Although 80.6 % of SLNs were in external iliac and interiliac areas, 38.2 % of patients had at least one SLN in an unexpected area and 5.1 % had SLNs only in unexpected areas. In unexpected areas, the number of SLNs per patient was not significantly different between lymphoscintigraphy and intraoperative detection (0.79 [0.62-1.02] versus 0.50 [0.37-0.68]; P = 0.096). In expected locations, there were significantly more blue and hot SLNs per patient than blue or hot SLNs (1.70 [1.45-1.99], 0.42 [0.30-0.57], 0.52 [0.39-0.69]). Of 28 metastatic SLNs, 17 contained micrometastases or ITCs. SLN involvement was found only by immunohistochemistry in 39.1 % of patients with positive nodes, and involved SLNs were located in unexpected areas in 17 % of those patients. CONCLUSIONS: Sentinel lymph node biopsy detects unusual drainage pathways and micrometastases in a substantial proportion of patients, thus improving nodal staging.

Novel use of contrast-enhanced sonography in the diagnosis of central uterine necrosis following embolization for postpartum hemorrhage.

Since 2007, we have identified 2 cases of central uterine necrosis after uterine arterial embolization for postpartum hemorrhage. Contrast-enhanced sonography showed an absence of enhancement of the internal myometrium. Magnetic resonance imaging with gadolinium confirmed the diagnosis. The images obtained for the first case were corroborated by histologic analysis from a hysterectomy done for sepsis. For the second case, contrast-enhanced sonography performed during a follow-up period of conservative treatment revealed a reduction of necrosis. Our study shows that contrast-enhanced sonography seems to be a useful examination as an adjunct to grayscale and power Doppler imaging in the diagnosis and follow-up of uterine necrosis.

Comparison of diagnostic accuracy of frozen section with imprint cytology for intraoperative examination of sentinel lymph node in early-stage endometrial cancer: results of Senti-Endo study.

BACKGROUND: In early-stage endometrial cancer, intraoperative examination of sentinel lymph nodes (SLNs) can predict nodal involvement and avoid a second surgical procedure. Our goal was to determine the diagnostic accuracy (DA) of intraoperative examination in diagnosing metastatic pelvic SLNs. METHODS: This was a retrospective study, including 125 patients with early stage endometrial cancer. Results of intraoperative examination by frozen section (FS) or imprint cytology (IC) were compared with final histology (serial sectioning and immunohistochemistry (IHC)). The diagnostic value of intraoperative examination was calculated. RESULTS: Of the 111 patients with SLNs detected (89%), 87 (78.5%) had an intraoperative examination (30 with FS and 57 with IC). Intraoperative examination detected SLN metastases in 9 of 16 patients with metastatic SLN at definitive histology (sensitivity = 56.3%): macrometastasis in 8 and micrometastasis in 1. Seven false-negative cases were found (43.7%; micrometastases in 6 and isolated tumor cells in 1). The DA of intraoperative examination was 92% (95% confidence interval (CI), 84-96.7). For FS and IC, DA was 97.3% (95% CI, 85.8-99.9) and 88% (95% CI, 75.7-95.5), respectively. CONCLUSIONS: FS has better DA than IC for intraoperative examination of SLNs in endometrial cancer. The main limitation of both techniques is in detecting micrometastasis and isolated tumor cells.

Upper margin of para-aortic lymphadenectomy in cervical cancer.

Patients with early stage cervical cancer routinely undergo pelvic lymphadenectomy. A para-aortic lymphadenectomy is only performed in the setting of grossly enlarged lymph nodes. In patients with locally advanced disease, a para-aortic lymphadenectomy is indicated particularly when pelvic nodes are suspicious for disease on preoperative imaging. There is no consensus about the extent of para-aortic lymph node dissection in these patients. We reviewed relevant literature to determine the extension of para-aortic lymphadenectomy in patients with cervical cancer in order to establish whether lymph node dissection up to the inferior mesenteric artery or higher to the level of renal vessels should be performed. We performed a systematic search (PubMed; up to June 2011) to review systematic complete para-aortic lymphadenectomy. According to our search, eight women (1.09%) had isolated para-aortic node metastases, of which two had only lymph node metastases above the inferior mesenteric artery.

Detection rate and diagnostic accuracy of sentinel-node biopsy in early stage endometrial cancer: a prospective multicentre study (SENTI-ENDO).

BACKGROUND: Retrospective single-centre series have shown the feasibility of sentinel lymph-node (SLN) identification in endometrial cancer. We did a prospective, multicentre cohort study to assess the detection rate and diagnostic accuracy of the SLN procedure in predicting the pathological pelvic-node status in patients with early stage endometrial cancer. METHODS: Patients with International Federation of Gynecology and Obstetrics (FIGO) stage I-II endometrial cancer had pelvic SLN assessment via cervical dual injection (with technetium and patent blue), and systematic pelvic-node dissection. All lymph nodes were histopathologically examined and SLNs were serial sectioned and examined by immunochemistry. The primary endpoint was estimation of the negative predictive value (NPV) of sentinel-node biopsy per hemipelvis. This is an ongoing study for which recruitment has ended. The study is registered with ClinicalTrials.gov, number NCT00987051. FINDINGS: From July 5, 2007, to Aug 4, 2009, 133 patients were enrolled at nine centres in France. No complications occurred after injection of technetium colloid and no anaphylactic reactions were noted after patent blue injection. No surgical complications were reported during SLN biopsy, including procedures that involved conversion to open surgery. At least one SLN was detected in 111 of the 125 eligible patients. 19 of 111 (17%) had pelvic-lymph-node metastases. Five of 111 patients (5%) had an associated SLN in the para-aortic area. Considering the hemipelvis as the unit of analysis, NPV was 100% (95% CI 95-100) and sensitivity 100% (63-100). Considering the patient as the unit of analysis, three patients had false-negative results (two had metastatic nodes in the contralateral pelvic area and one in the para-aortic area), giving an NPV of 97% (95% CI 91-99) and sensitivity of 84% (62-95). All three of these patients had type 2 endometrial cancer. Immunohistochemistry and serial sectioning detected metastases undiagnosed by conventional histology in nine of 111 (8%) patients with detected SLNs, representing nine of the 19 patients (47%) with metastases. SLN biopsy upstaged 10% of patients with low-risk and 15% of those with intermediate-risk endometrial cancer. INTERPRETATION: SLN biopsy with cervical dual labelling could be a trade-off between systematic lymphadenectomy and no dissection at all in patients with endometrial cancer of low or intermediate risk. Moreover, our study suggests that SLN biopsy could provide important data to tailor adjuvant therapy. FUNDING: Direction Interrégionale de Recherche Clinique, Ile-de-France, Assistance Publique-Hôpitaux de Paris.

A Home-Mailed Versus General Practitioner-Delivered Vaginal Self-Sampling Kit for Cervical Cancer Screening: A Cluster Randomized Controlled Trial with a Cost-Effectiveness Analysis.

Objective: We assessed whether general practitioner (GP) delivery of a vaginal self-sampling kit was non-inferior to home-mailed delivery on cervical cancer screening (CCS) participation. Methods: Two hundred and ten French GPs from Indre-et-Loire French department were randomized into two groups, and their unscreened women patients aged 30-65 were included in February-March 2015. In the GP delivery group (n = 105 GPs; 1,806 women), women were sent a reminder letter inviting them to collect a vaginal self-sampling kit at their regular GP's practice. In the home-mailed delivery group (n = 105 GPs; 1,806 women), women were sent a reminder letter with a vaginal self-sampling kit directly at home. The primary outcome was participation in complete CCS within 9 months. A cost-effectiveness analysis was also performed. Results: At 9 months, 14.9% (95% CI: 12.9-16.9) and 27.9% (95% CI: 25.7-30.0) of women in the GP and home-mailed delivery groups participated in complete CCS. The absolute between-group difference was -13.0 percentage points (95% CI: -15.9 to -10.0) in favor of the home-mailed delivery group, crossing the non-inferiority pre-defined non-inferiority margin of 5%. The home-mailed delivery strategy cost 50.81€ more per additional woman screened. Conclusions: The GP delivery was inferior to home-mailed delivery in increasing participation in CCS. Home-mailed delivery of a vaginal self-sampling kit is a cost-effective way to increase CCS in that the additional cost of this strategy seems acceptable. This study is registered at www.Clinicaltrials.gov NCT02255084.

Diagnostic value of intraoperative examination of sentinel lymph node in early cervical cancer: a prospective, multicenter study.

OBJECTIVES: Sentinel lymph node (SLN) biopsy is a surgical procedure proposed in early cervical cancer. This technique yields the potential interest to reduce the morbidity of complete lymphadenectomy, which could then be performed only in case of positive SLN. Intraoperative examination has a major per-operative role in predicting nodal involvement and preventing a second step procedure. The aim of this study was to assess the diagnostic value of intraoperative examination with frozen section (FS) or imprint cytology (IC) of SLNs in early cervical cancer. METHODS: Prospective study in 7 centers (01/2005-06/2007) including patients with stage IA1 and lymphovascular space involvement to IB1 cervical cancer (squamous cell carcinoma, adenocarcinoma or adenosquamous carcinoma). SLNs were detected with a combined method (Tc99m+blue dye) and then removed laparoscopically. Intraoperative examination (FS or IC) was not systematically performed but recommended in case of macroscopical nodal enlargement in 5 centers. Results of intraoperative examination were compared with final histology performed by Hematoxylin-Eosin-Safran staining and immunohistochemistry. The diagnostic value of intraoperative examination was calculated. RESULTS: One hundred and thirty-nine patients were analyzed in the study. The combined detection rate was 97.8% per patient, with 454 detected SLNs. One hundred and two patients (73.4%) had an intraoperative examination (97 patients with FS and 5 with IC). Among patients with intraoperative examination, 5 SLNs were positive (all with macrometastasis at final histology), as compared with 22 metastatic nodes at final result. The 17 false negative SLNs were: 4 macrometastasis, 4 micrometastasis and 9 isolated tumor cells. Sensitivity of the intraoperative examination per node was 20.7% [95%CI: 7.8%-45.4%] and the negative predictive value 93.0% [95%CI: 89.0%-95.9%]. CONCLUSIONS: Intraoperative examination of SLNs by FS and IC has a poor diagnostic value. This is mainly related to micrometastasis and isolated tumor cells, which are not detected by intraoperative techniques. Other techniques, like new molecular assays, should be investigated to improve intraoperative assessment of SLNs.

Clinical practice guidelines for the management of patients with endometrial cancer in France: recommendations of the Institut National du Cancer and the Société Française d'Oncologie Gynécologique.

INTRODUCTION: Endometrial cancer is the most common gynecological malignancy in France, with more than 6500 new cases in 2010. The French National Cancer Institute has been leading a clinical practice guidelines (CPG) project since 2008. This project involves the development and updating of evidence-based CPG in oncology. OBJECTIVE: To develop CPG for diagnosis, treatment, and follow-up for patients with endometrial cancer. METHODS: The guideline development process is based on systematic literature review and critical appraisal by experts, with feedback from specialists in cancer care delivery. The recommendations are thus based on the best available evidence and expert agreement. RESULTS: Main recommendations include a routine pelvic magnetic resonance imaging in association with magnetic resonance imaging exploration of the para-aortic lymph nodes for locoregional staging, surgical treatment based on total hysterectomy with bilateral salpingo-oophorectomy with or without lymphadenectomy, and clinical examination for the follow-up. The initial laparoscopic surgical approach is recommended for stage I tumors. Lymphadenectomy and postoperative external radiotherapy are recommended for patients with high risk of recurrence but are restricted for patients with low or intermediate risk. If brachytherapy is indicated, it should be given at a high-dose rate rather than a low-dose rate. Routine imaging, biologic tests, and vaginal smears are not indicated for follow-up.

Mammoplasty for symmetry in breast reconstruction and histologic assessment.

BACKGROUND: In breast reconstruction, complementary surgery on the contralateral breast is sometimes necessary to obtain a satisfactory aesthetic result. This complementary mammoplasty for symmetry gives the surgeon the opportunity to verify the state of the mammary glandular tissue to rule out a possible occult tumour in the contralateral breast. Our objective was to determine the prevalence of borderline lesions and of in situ and invasive carcinoma in specimens of the contralateral breast in a mammoplasty for symmetry in patients with breast cancer. METHODS: We conducted a retrospective study of 145 breast reconstructions with mammoplasty for symmetry conducted at the Tours Regional Teaching Hospital in France. RESULTS: The glandular histologic result after mammoplasty was normal in 45.5% of patients, with benign pathologies in 38.9% and borderline lesions in 15.6% of patients. No invasive or in situ carcinoma was detected. CONCLUSION: Systematic histologic analysis of glandular mammary tissue sampled after reduction mammoplasty in the particular context of breast reconstruction after breast cancer makes it possible to discover lesions that were not seen in presurgical evaluation. The early management of these borderline occult lesions could reduce the incidence of breast cancer in these at-risk patients.

Ovarian arteries embolization in women with persistent symptoms following uterine arteries embolization for uterus fibroids.

PURPOSE: In patients with persisting symptoms after uterine arteries embolization (UAE), ovarian arteries embolization (OAE) may play a role to improve symptoms and decrease subsequent surgery rates. In a retrospective cohort, we aimed to investigate the efficacy and safety of OAE in females with recurrent or persistent symptoms following UAE. METHODS: We performed a retrospective analysis of prospectively collected cases at a single reference academic hospital; we identified patients who benefited from OAE for persisting symptoms following UAE from 2008 to 2021. Outcome variables included the rates of subsequent surgery, a quality-of-life questionnaire with the UFS-QOL tool, the MRI reduction in uterine and fibroids volumes and the fibroid devascularization rate. RESULTS: Among 1300 women treated with UAE during the study period, 18 eventually received OAE and were included (mean age 44 ± 4.3 SD). There was no OAE procedural complication. There was a decrease in uterine volume and a complete devascularization of the dominant fibroid in 10/11 (90.9%) patients who underwent 12 months MRI. Three women underwent subsequent hysterectomy. Among 10/18 patients who answered the quality-of-life questionnaire after a mean follow-up of 70 months, eight reported an improvement or stability of symptoms. CONCLUSION: OAE for persisting symptoms after UAE was associated with improvement or stability of quality-of-life in most study subjects and less than a fifth of the cohort underwent hysterectomy after OAE. This study highlights the role of OAE as an adjunct to UAE.

Preoperative diagnosis of ovarian tumors using pelvic contrast-enhanced sonography.

OBJECTIVE: The purpose of this study was to assess the feasibility of using a contrast agent for the sonographic examination of adnexal tumors and identify discriminating parameters in the preoperative diagnosis of malignant tumors. METHODS: We conducted a prospective descriptive monocenter study that analyzed validated echographic criteria and parameters of the enhancement curve obtained by sonographic contrast agent injection. Patients included were referred for a second opinion after the discovery of a suspicious ovarian image. The final diagnosis was reached after surgery and an anatomopathologic examination. RESULTS: Fifty-two tumors were analyzed. Morphologic and Doppler criteria analyses were conducted as described in the literature. The significant parameters of the enhancement curve were the time-intensity curve total area and the duration of activity of the contrast agent during the first phase of decay (P < .002). The performance of the contrast agent was lower than that of the examiner's subjective diagnosis, with an area under the receiver operating characteristic curve (AUC) of 0.78 versus 0.80. When borderline tumors were eliminated, there was an inversion of this, with an AUC of 0.85 versus 0.73. The inclusion of contrast results in the examiner's diagnosis in the context of a bivariate model comparing malignant and borderline tumors with benign tumors provided an AUC of 0.88. CONCLUSIONS: Contrast-enhanced sonography improves preoperative diagnosis of ovarian tumors parameters. The significant parameters of the enhancement curve were significantly different for malignant and benign tumors. Borderline tumors contribute to a reduction of the discriminating capacity of the contrast agent.

Experience implication in subjective surgical ergonomics comparison between laparoscopic and robot-assisted surgeries.

INTRODUCTION: Laparoscopic surgery (LS) may lead to musculoskeletal disorders (MSDs) and an increase in physical and mental workloads to the surgeon. Robot-assisted surgery (RAS) should improve the ergonomy of the surgeon. This study assesses the experience influence in surgical ergonomics between LS and RAS. METHODS: LS and RAS lasting more than 60 min of effective operative time were compared. During the surgical procedure, the physical discomfort was evaluated using the Borg scale. At the end, the mental workload was evaluated using the NASA-TLX index. After global analysis, the experienced and young surgeons were assessed. RESULTS: 88 RAS and 82 LS were evaluated. During LS, the physical discomfort was significantly higher in all segments, and the pain increased significantly during the procedure in all segments compared to that evaluated in the RAS (p < 0.05). Forearms and the back were the most painful. The young surgeons did not display any improvement in the physical ergonomics of the RAS compared to the LS. Concerning the mental ergonomics, the overall workload and performance were significantly greater during the LS compared to the RAS (p < 0.05). For the young surgeons, the overall workload, the effort, the mental and the physical demands were greater during LS (p < 0.05). For the experienced surgeons, the physical demand was lower during the RAS compared to the LS (p < 0.05). However, the experienced surgeons expressed a feeling of greater performance after the LS (p < 0.01). RAS significantly reduces the onset of MSDs compared to LS, especially for the experienced surgeons. CONCLUSION: RAS significantly reduces the onset of MSDs compared to LS, especially for the experienced surgeons.

French recommendations on the management of invasive cervical cancer during pregnancy.

BACKGROUND: Cervical cancer is one of the most frequently diagnosed cancers during pregnancy, but the management of such cases remains unclear. A Working Group was set up in 2007 in France to propose national recommendations for the management of pregnant patients with invasive cervical carcinoma. METHODS: The recommendations are based on this literature review conducted by the members of the Working Group. RESULTS: Management of cervical cancer during pregnancy depends on 5 factors: stage of the disease (and the tumor size), nodal status, histological subtype of the tumor, term of the pregnancy, and whether the patient wishes to continue her pregnancy. In patients with early-stage disease diagnosed during the first 2 trimesters of pregnancy, there is an increasing tendency to preserve the pregnancy while awaiting fetal maturity in patients with absence of nodal involvement. The delivery (when the fetal maturity is attained) should be then performed using a cesarean section. CONCLUSIONS: This article proposes recommendations for the management of pregnant patients with invasive cervical cancer. These recommendations have been validated by the 3 main scientific societies of gynecologic oncology, pelvic surgery, and obstetrics and gynecology in France.

Broad-Range Papillomavirus Transcriptome as a Biomarker of Papillomavirus-Associated Cervical High-Grade Cytology.

Human papillomaviruses (HPVs) are responsible for >99% of cervical cancers. Molecular diagnostic tests based on the detection of viral DNA or RNA have low positive predictive values for the identification of cancer or precancerous lesions. Triage with the Papanicolaou test lacks sensitivity; and even when combined with molecular detection of high-risk HPV, this results in a significant number of unnecessary colposcopies. We have developed a broad-range detection test of HPV transcripts to take a snapshot of the transcriptome of 16 high-risk or putative high-risk HPVs in cervical lesions (HPVs 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, 68, 73, and 82). The purpose of this novel molecular assay, named HPV RNA-Seq, is to detect and type HPV-positive samples and to determine a combination of HPV reads at certain specific viral spliced junctions that can better correlate with high-grade cytology, reflecting the presence of precancerous cells. In a proof-of-concept study conducted on 55 patients, starting from cervical smears, we have shown that HPV RNA-Seq can detect papillomaviruses with performances comparable to a widely used HPV reference molecular diagnostic kit; and a combination of the number of sequencing reads at specific early versus late HPV transcripts can be used as a marker of high-grade cytology, with encouraging diagnostic performances as a triage test.

Clinical practice guidelines for contraception by the French National College of Gynecologists and Obstetricians (CNGOF).

The French College of Obstetrics and Gynecology (CNGOF) has released its first comprehensive recommendations for clinical practices in contraception, to provide physicians with an updated synthesis of the available data as a basis for their practice. The organizing committee and the working group adopted the objective methodological principles defined by the French Authority for Health (HAS) and selected 12 themes relevant to medical professionals' clinical practices concerning contraception. The available literature was screened through December 2017 and served as the basis of 12 texts, reviewed by experts and physicians from public and private practices, with experience in this field. These texts enabled us to develop evidence based, graded recommendations. Male and female sterilization, as well as the use of hormonal treatments not authorized for contraception ("off-label") were excluded from the scope of our review. Specific practical recommendations are provided for the management of contraception prescription, patient information concerning effectiveness, risks, and benefits of the different methods, patient follow-up, intrauterine contraception, emergency contraception, local and natural methods, contraception in teenagers, in women after 40, for women at high thromboembolism or cardiovascular risk, and for those at of primary cancer or relapse. The short- and mid-term future of contraception depends mainly on improving the use of currently available methods. This includes reinforced information for users and increased access to contraception for women, regardless of their social and clinical contexts. The objective of these guidelines is to aid in enabling this improvement.