[Sentinel lymph node biopsy in invasive breast cancer in 2009]. / Mise au point sur le prélèvement du ganglion sentinelle dans le cancer invasif du sein en 2009.

Sentinel lymph node biopsy (SLNB) has become an alternative to axillary lymph node dissection (ALND) despite the limited recidive long-term results. SLNB can not only reduce ALND morbidity but also provide ultrastadification with serial sectionning and immunohistochemistry analysis which increase the sensitivity of detection of sentinel node (SN) metastasis. Micrometastasis or isolated tumor cells are frequently discovered. However, their diagnostic and pronostic values are still subject to controversy. Most of large randomized trials have determined that double detection (colorimetric and isotopic) improved SN identification rate and decreased false negative rate; and that periareolar injection was equally effective, even superior than peritumoral injection with the major advantage of its simplicity in non palpable tumors. One of the unsolved problems of SLNB is to determine if its indications may be extended to larger tumors, to node sampling before or after neoadjuvant chemotherapy, or after previous lumpectomy or breast surgery, in case of palpable axillary node, and in case of multifocal tumor. Another challenge is to determine if complementary ALND in case of SLND metastasis is necessary, because 40 to 70% of non sentinel nodes (NSN) are tumor-free. Several predictive models (nomograms, scores, partitioning recursive models) have been developed to predict non-SN status in SN-positive patients. These models must be validated in independent cohorts to enable their use in routine.

Prognosis of patients who relapse after fertility-sparing surgery in epithelial ovarian cancer.

BACKGROUND: The prognosis for patients who develop a recurrence after fertility-sparing surgery for epithelial ovarian cancer (EOC) remains unclear. This is the first study to evaluate survival in patients who have developed a recurrence in this context. METHODS: The outcomes of relapsed patients reported in the literature in the four main series of fertility-sparing surgery for EOC were reviewed and updated (where feasible). RESULTS: Twenty-three of the 166 patients in the series were reported to have recurrent disease. The site of the recurrence was the peritoneum (+/- remaining ovary) in 17 patients, and distant in six patients. Twelve patients died of recurrent disease, two are still alive with persistent disease, eight are disease-free, and one is alive but her exact status is not known. Among eight patients (34%) with an isolated recurrence on the remaining ovary, two died and one was lost to follow-up. CONCLUSION: In this carefully monitored population, including systematic radiological examinations, the rate of isolated recurrences on the spared ovary is low. Recurrence in these patients carries a poor prognosis. Such results suggest that initial selection of candidates for fertility-sparing surgery should be carefully defined to reduce the rate of recurrences that carry a poor prognosis.

Human placental development is impaired by abnormal human chorionic gonadotropin signaling in trisomy 21 pregnancies.

Placental development is markedly abnormal in women bearing a fetus with trisomy 21, with defective syncytiotrophoblast (ST) formation and function. The ST occurs from cytotrophoblast (CT) fusion and plays an essential role by secreting human chorionic gonadotropin (hCG), which is essential to placental development. In trisomy of chromosome 21 (T21) pregnancies, CTs do not fuse and differentiate properly into STs, leading to the secretion of an abnormal and weakly bioactive hCG. In this study we report for the first time, a marked decrease in the number of mature hCG receptor (LH/CG-R) molecules expressed at the surface of T21-affected CTs. The LH/CG-R seems to be functional based on sequencing that revealed no mutations or deletions and binding of recombinant hCG as well as endogenous hCG. We hypothesize that weakly bioactive hCG and lower LH/CG-R expression may be involved in the defect of ST formation. Interestingly, the defective ST formation is mimicked in normal CT cultures by using LH/CG-R small interfering RNA, which result in a lower hCG secretion. Furthermore, treatment of T21-affected CTs with recombinant hCG overcomes in vitro the T21 phenotype, allowing CTs to fuse and form a large ST. These results illustrate for the first time in trisomy 21 pathology, how abnormal endogenous hCG signaling impairs human placental development.

Bilateral tubal pregnancy after natural conception: a case report.

BACKGROUND: Bilateral tubal pregnancy is very rare and usually follows ovulation stimulation. CASE: A 36-year-old woman with acute pelvic pain underwent emergency laparoscopy for suspected left ruptured tubal pregnancy. Bilateral hematosalpinx with a ruptured left tubal pregnancy and active bleeding from the right fallopian tube was noted during surgery, and bilateral salpingectomy was performed by laparoscopy. Pathologic examination of the left tube confirmed the presence of conception products and trophoblastic tissue. The right salpingectomy specimen contained some trophoblastic tissue resembling an earlier tubal pregnancy encased in a cyst. CONCLUSION: This was a rare case of spontaneous bilateral tubal pregnancy after conception at different times. The explanation of the presentation is uncertain. Laparoscopy remains the cornerstone of diagnosis and treatment in the majority of women with a tubal pregnancy; this is especially true in complex cases, such as bilateral tubal pregnancy.

Nomogram to predict subsequent brain metastasis in patients with metastatic breast cancer.

PURPOSE Brain metastasis is usually a fatal event in patients with stage IV breast cancer. We hypothesized that its occurrence can be predicted if a clinical nomogram can be developed, thus allowing for selection of enriched patient populations for prevention trials. PATIENTS AND METHODS Electronic medical records of patients with metastatic breast cancer were retrospectively reviewed for the period between January 2000 and February 2007 under a study approved by the institutional review board. A multivariate logistic regression analysis of selected prognostic features was done. A nomogram to predict brain metastasis was constructed and validated in a cohort of 128 patients with brain metastasis treated at the Cross Cancer Institute (Edmonton, Alberta, Canada). Results Of 2,136 patients with breast cancer, 362 developed subsequent brain metastasis. Age, grade, negative status of estrogen receptor and human epidermal growth factor receptor 2, number of metastatic sites (one v > one), and short disease-free survival were significantly and independently associated with subsequent brain metastasis. The nomogram showed an area under the receiver operating characteristic curve (AUC) of 0.68 (95% CI, 0.66 to 0.69) in the training set. The validation set showed a good discrimination with an AUC of 0.74 (95% CI, 0.70 to 0.79). The nomogram was well calibrated, with no significant difference between the predicted and the observed probabilities. CONCLUSION We have developed a robust tool that is able to predict subsequent brain metastasis in patients with breast cancer with nonbrain metastatic disease. Selection of an enriched patient population at high risk for brain metastasis will facilitate the design of trials aiming at its prevention.

Biochemical characterization and modulation of LH/CG-receptor during human trophoblast differentiation.

Due to the key role of the human chorionic gonadotropin hormone (hCG) in placental development, the aim of this study was to characterize the human trophoblastic luteinizing hormone/chorionic gonadotropin receptor (LH/CG-R) and to investigate its expression using the in vitro model of human cytotrophoblast differentiation into syncytiotrophoblast. We confirmed by in situ immunochemistry and in cultured cells, that LH/CG-R is expressed in both villous cytotrophoblasts and syncytiotrophoblasts. However, LH/CG-R expression decreased during trophoblast fusion and differentiation, while the expression of hCG and hPL (specific markers of syncytiotrophoblast formation) increased. A decrease in LH/CG-R mRNA during trophoblast differentiation was observed by means of semi-quantitative RT-PCR with two sets of primers. A corresponding decrease ( approximately 60%) in LH/CG-R protein content was shown by Western-blot and immunoprecipitation experiments. The amount of the mature form of LH/CG-R, detected as a 90-kDa band specifically binding (125)I-hCG, was lower in syncytiotrophoblasts than in cytotrophoblasts. This was confirmed by Scatchard analysis of binding data on cultured cells. Maximum binding at the cell surface decreased from 3,511 to about 929 molecules/seeded cells with a kDa of 0.4-0.5 nM. Moreover, on stimulation by recombinant hCG, the syncytiotrophoblast produced less cyclic AMP than cytotrophoblasts, indicating that LH/CG-R expression is regulated during human villous trophoblast differentiation.

Site-select procedure for non-palpable breast lesions: feasibility study with a 15-mm cannula.

BACKGROUND: As screening mammography becomes more commonplace, increasing numbers of non-palpable breast lesions are being found. The aim of this prospective study was to evaluate the feasibility, utility, and patient-perceived cosmesis and satisfaction of the Site-Select procedure in women with non-palpable breast lesions. METHODS: Thirty-two consecutive patients underwent the Site-Select procedure, performed under local anesthesia by the same surgeon. The Site-Select procedure was included in a protocol for small (<15 mm) breast imaging reporting and data system (BI-RADS) grade 3 and 4 breast lesions. The pathologic diagnosis, specimen size, length of the procedure, perioperative and postoperative complications, subsequent interventions, patient satisfaction, and esthetic results were documented. RESULTS: The Site-Select procedure was successful in all 32 patients (mean age, 56 years; range, 44-79 years). Mammographic lesions corresponded to microcalcifications in 21 patients, microcalcifications with architectural distortion in 4 patients, microcalcifications with nodules in 2 patients, and architectural distortion alone in 5 patients. The Site-Select procedure was used on an outpatient basis. Carcinomas were diagnosed in five patients (15.6%). No complications occurred during the procedure. The only postoperative complication was a hematoma, which did not require surgical drainage. No missed cancers were detected by follow-up mammography (mean 8 months later; range, 1-18 months). The esthetic results and patient satisfaction were excellent. CONCLUSIONS: This study demonstrates that the Site-Select procedure is an effective diagnostic method in selected cases. It has a low complication rate, high patient satisfaction, and excellent esthetic results.

Fertility after laparoscopic colorectal resection for endometriosis: preliminary results.

OBJECTIVE: To examine fertility, reproductive outcomes, and determinants of fertility after laparoscopic segmental colorectal resection for endometriosis. DESIGN: Retrospective longitudinal study. SETTING: Tertiary university gynecology unit. PATIENT(S): The study population consisted of 34 women with colorectal endometriosis, of whom 22 wished to conceive. Demographic, surgical, and histological characteristics of 10 women who conceived were compared with those of 12 women who failed to conceive. INTERVENTION(S): Laparoscopic colorectal resection for endometriosis. MAIN OUTCOME MEASURE(S): Rates of pregnancy and live birth. RESULT(S): Mean follow-up after segmental colorectal resection was 24 months (range 6-42 months), and the pregnancy rate was 45.5%. The median time to conceive was 8 months (range 3-13 months). Twelve pregnancies occurred in 10 women, comprising nine spontaneous singleton pregnancies (7 vaginal deliveries, 1 cesarean section, and 1 ongoing pregnancy), and three pregnancies obtained by IVF (one miscarriage, one ongoing twin pregnancy, and one triplet pregnancy necessitating cesarean section at 29 weeks for premature rupture of the membranes, with two surviving infants). The live birth rate was 82%. The women who did and did not conceive did not differ in terms of mean follow-up, mean age, body mass index (BMI), parity, smoking, use and duration of oral contraception (OC), duration of infertility, or the length of the resected colorectal segment. Uterine adenomyosis was the main determinant of pregnancy after colorectal resection. CONCLUSION(S): These preliminary results suggest that extensive laparoscopic segmental colorectal resection for endometriosis can enhance fertility, with high rates of spontaneous pregnancy and live birth.

Contralateral axillary sentinel lymph node drainage in breast cancer: a case report.

BACKGROUND: Since the introduction of sentinel node (SN) mapping in breast cancer, extra-axillary lymph node sites of breast tumor drainage are discovered in about one-quarter of cases, especially after intraparenchymal injection. In most such cases, an ipsilateral axillary SN is associated with an extra-axillary SN. Non visualization of ipsilateral axillary SN and extra-axillary SN drainage are often associated with an increased risk of axillary involvement. CASE: We report a case of contralateral axillary SN drainage on lymphoscintigraphy in a breast cancer patient with a history of bilateral reduction mammoplasty and no ipsilateral axillary lymph node involvement.