Indocyanine Green Fluorescence-Guided Sentinel Node Biopsy in Breast Cancer Within a North African Population: A Retrospective Study.

OBJECTIVE: Radio isotopes and blue dyes alone or in combination are the most commonly used tracer agents in sentinel node (SN) biopsy for early breast cancer. Recent studies have found fluorescence method using indocyanine green (ICG) as a promising technology with fewer disadvantages. MATERIALS AND METHODS: Retrospective analysis of our database that included patients with clinically node-negative breast cancer scheduled for breast surgery and SN biopsy between 2016 and January 2021. Patients who underwent detection using fluorescence-ICG were included in this study. RESULTS: A total of 47 patients were included. Median age was 50 (range: 24-78) years. Mean tumor size was 3.4 ± 1.5 cm. All patients received ICG injection and 11 received a combination of ICG and blue dye. Forty-five successful SN identifications with ICG were performed and 99 nodes retrieved. Eleven procedures were undertaken after initial systemic therapy. Twenty-four patients had at least one positive SN for malignancy. Mean follow up was 29.2 months and no axillary recurrence was noted during the study period. CONCLUSION: ICG appears to be a feasible and accurate method for SN biopsy with high identification rate. This is the first study of ICG in sentinel node biopsy in a North African population.

Office hysteroscopy before first in vitro fertilization. A randomized controlled trial.

BACKGROUND: Implantation failure remains a mystery since decades. This procedure needs a "top quality embryo" and a "normal" uterine cavity. To assess uterine cavity before first in vitro fertilization (IVF), many diagnostic tools could be used. Hysteroscopy remains the gold standard to diagnose and treat intra-uterine anomalies. However, it is not clearly recommanded to offer an office hysteroscopy before first IVF when transvaginal ultrasound (TVUS) and hysterosalpingography (HSG) were normal. PURPOSE: This study aimed to assess the role of office hysteroscopy before first IVF when no intra-uterine anomalies are suspected. BASIC PROCEDURES: We conducted a randomized controlled trial including 171 women scheduled for their first IVF. Women were assigned to either Group I: office hysteroscopy before IVF or Group II: immediate IVF. We included women aged less than 40 years, having regular cycles, FSH levels less than10UI/l, antral follicular count ≥12, normal TVUS and HSG. Their body mass index (BMI) ranged from 19 to 30 kg/m2. We excluded patients known having severe endometriosis, polycystic ovarian syndrome (PCOS) and oocyte receivers. The primary outcome were livebirth rate and clinical pregnancy rate. MAIN FUNDINGS: Between january 2016 and september 2017, we randomly assigned 171 women to either Group I (n = 84) or Group II (n = 87). Hysteroscopy was done in the mid-follicular phase immediately before IVF. Baseline characteristics and IVF features were comparable between groups except for the IVF protocol. Live birth rate was 23,9% in Group I versus 19,3% in Group II. (p = 0,607). Clinical Pregnancy rate was 32,4% in Group I versus 21,7% in Group II. (p = 0,326). No statistical significance was observed for neither miscarriage rate nor multiple pregnancy rate. Hysteroscopy showed 30% unsuspected intra-uterine anomalies: 11 intra-uterine adhesions, 7 polyps, 7 clinical endometritis and one fibroid print. Therapeutic hysteroscopy was done only for 6 intra-uterine adhesions and 3 polyps. Other anomalies did not require operative hysteroscopy. Visual analog score during hysteroscopy was 4,69 +/-2,892. 5 women (6%) of Group I experienced discomfort during diagnostic hysteroscopy. Only one patient had vagal syncope. No further complications were observed. PRINCIPAL CONCLUSIONS: Office hysteroscopy before first IVF seems not improve IVF results. Minimal intra-uterine anomalies not diagnosed by transvaginal ultrasound and hysterosalpingography do not seem to reduce IVF results.

The influence of gonadotropins on clinico-biological ICSI outcome: a retrospective comparative study rFsH vs HP-hmg.

Objective To investigate the difference in the outcome of ICSI-ET cycles among respondents patients, taking into account the molecule inducer of controlled ovarian stimulation: HP-hMG ou rFSH. Patients and Methods A comparative retrospective study over 62 months including a total of 1005 infertile couples, divided into two groups: HP-HMG (n=125) and rFSH (n=880). Results - The average numbers of retrieved oocytes and matures oocytes were significantly higher in rFSH group rFSH (7,94 ± 2,49, HP-HMG vs 9,05 ± 3,40, rFSH, p=0.0001and  3±2,68, HP-HMG vs 6,65±3,05 , rFSH, p=0,02 respectively). There was no statistically significant difference in the endometrial thickness and estradiol level on hCG injection day, the total amount of administrated gonadotropin and the duration of stimulation. In addition, we did not find a significant difference between the two groups regarding the fertilization, the maturation, the cleavage, top quality embryo, implantation, clinical pregnancy, multiple pregnancies, live birth and miscarriage rates. There was no case of severe ovarian hyperstimulation syndrome. Conclusion - Inspite of a higher number of retrieved and mature oocytes obtained with rFSH, the latter showed no superiority over HP-hMG which seem to be equally efficient and safe for ICSI treatment cycles.

Unusual gestational choriocarcinoma arising in an interstitial pregnancy.

INTRODUCTION: Choriocarcinoma is a highly malignant trophoblastic neoplasm. Its association with ectopic pregnancy is very rare and usually with aggressive behavior. PRESENTATION OF CASE: We report a new case arising in an interstitial pregnancy occurring in a 46-year-old woman. The patient was admitted for severe pelvic pain and abundant metrorrhagia. One month ago, she had had a laparoscopic resection of an interstitial pregnancy subsequent to failure of chemotherapy by methotrexate. The raise of serum ßhCG level and the hyperechoic intrauterine mass were in favor of gestational trophoblastic disease. Urgent laparotomy was performed for circulatory collapse. Hysterectomy was done. Histological examination revealed a choriocarcinoma. The patient underwent chemotherapy. Two years later, neither metastasis nor recurrence was detected. DISCUSSION: Clinical diagnosis of primary interstitial choriocarcinoma is difficult, since it is rare and manifesting by non-specific abnormal vaginal bleeding. Imaging findings are also not helpful in ectopic location. The frequency of metastasis is related to the delayed diagnosis. Serial measurement of ßhCG level was the most useful marker of diagnosis and follow up. Histopathological examination remains the only tool of the precise diagnosis. Choriocarcinoma has a very good prognosis even in advanced stages, since it is very chemosensitive. CONCLUSION: The current trend of the treatment of ectopic pregnancy by conservative surgery requires adequate monitoring of ßhCG and careful examination of pathologic specimens to avoid misdiagnosis of ectopic gestational trophoblastic disease.

Ewing's Sarcoma: An Uncommon Breast Tumor.

Ewing's sarcoma/primitive neuroectodermal tumors (EWS/PNET) are rare malignant and aggressive tumors, usually seen in the trunk and lower limbs of children and young adults. They are uncommon in the breast. We report a case of a 43-year-old woman who developed a painless breast mass. An initial core needle biopsy concluded to a fibrocystic dystrophy contrasting with a rapidly growing mass; thus a large lumpectomy was done. Diagnosis of primary PNET of the breast was established, based on both histopathological examination and immunohistochemical findings. Surgical margins were positive, therefore, left modified radical mastectomy with axillary lymph nodes dissection was performed. The patient was given 6 cycles of adjuvant chemotherapy containing cyclophosphamide, adriamycin and vincristine. Twenty months later, she is in life without recurrence or metastasis. EWS/PNET may impose a diagnostic challenge. Indeed, mammography and ultrasonography features are non specific. The histopathological pattern is variable depending on the degree of neuroectodermal differentiation. Immuno-phenotyping is necessary and genetic study is the only confirmatory tool of diagnosis showing a characteristic cytogenetic anomaly; t (11; 22) translocation.

[Clinicopathologic characteristics and prognosis factors of uterine sarcomas in central Tunisia]. / Caractéristiques clinicopathologiques et facteurs pronostiques des sarcomes utérins dans le centre tunisien.

To analyze the clinical and pathological features of uterine sarcomas treated at our referral medical center. The aim of the study is also to analyze their prognosis factors. We performed a retrospective analysis of 40 women with uterine sarcoma treated at the Obstetrics and Gynecology department - Sousse - Tunisia between 1997 and 2010. Tumor stage was assessed according to the FIGO 1988 classification. Patient's outcomes were recorded and analyzed using SPSS 18.0 program. Forty patients were included in the study. Leiomyosarcoma represents 65% of cases (n=26) and carcinosarcoma 20 % (n=8). Mean age at the time of diagnosis was 53 years (range: 35-82 years). The most common symptoms were vaginal bleeding and pelvic pain (respectively 72.5% and 45%). Mean interval time from onset of symptoms and pathological diagnosis of sarcoma was 16 weeks (range: 0 to 96 weeks). Definitive diagnosis of sarcoma was achieved after pathological analysis in 62.5%. Most common histological type was leiomyosarcoma in 65 % of cases. A total of 36 patients underwent total hysterectomy with bilateral salpingo-oophorectmy. In four cases pelvic lymphadenectomy was also performed. 75% (n=30) were in FIGO stage I. Eleven patients underwent external pelvic radiotherapy and chemotherapy was administrated in three cases. At the time of study, mean follow up was 30.9 months (range: 0 to 120 months). The 5-year global survival and free survival were 17.5% and 15%, respectively. In multivariate analysis tumor stage was found to be the strongest prognostic factor. Mean survival was 71 months in FIGO stage I, 13.4 months in FIGO stage II, 10 months in FIGO stage III and 4,8 months in FIGO stage IV(p<0,001). Uterine sarcomas are rare. Leiomyosarcoma is the most common histological type. Pathological diagnosis is usually achieved after radical surgery. Prognosis is poor and is correlated with tumor stage.

The uterine choriocarcinoma in postmenopausal women: specificities of diagnosis and treatment.

Choriocarcinoma is a gestational trophoblastic tumor that mainly affects women of childbearing age. Cases of choriocarcinoma in postmenopausal women are exceptional. Through an observation and literature review, we propose to study the specific diagnosis and treatment features of this tumor in menopausal women. We report the observation of a pure uterine choriocarcinoma, which occurred in post-menopause. The diagnosis was made on the analysis of surgical specimens confirmed by measurement of hCG. Chemotherapy was started after a total hysterectomy and bilateral salpingo-oophorectomy first. The improvement was dramatic after 3 courses of chemotherapy and the patient is in complete remission after five years of monitoring. The primitive forms of pure choriocarcinoma in postmenopausal women are exceptional. Their etiology is poorly understood and their treatment based on chemotherapy.

Mammary-like adenocarcinoma of the vulva associated to Paget's disease: a case report.

Mammary-like adenocarcinoma of the vulva associated to Paget's disease is exceedingly rare. So, it is very important to perform all the pathological and immunohistochemical investigations to achieve differential diagnosis from both a metastatic lesion from an orthotopic breast cancer and a vulvar adnexal tumor. This report describes a case of vulvar Paget's disease associated with underlying mammary-like adenocarcinoma diagnosed in the Department of Obstetrics and Gynecology of Farhat Hached university hospital of Sousse in Tunisia. We also review previously reported cases of primary breast-like carcinoma of the vulva with or without Paget's disease.

Validation of nomograms to predict the risk of non-sentinels lymph node metastases in North African Tunisian breast cancer patients with sentinel node involvement.

INTRODUCTION: In approximately half of patients with breast cancer and lymph node metastases, the sentinel node (SN) is the only involved axillary node. Scoring systems have been developed to predict probability of non-SN metastases among those with a positive SN. The goal of the present study was to determine whether the five models (Memorial Sloan-Kettering Cancer Center (MSKCC), Stanford, Tenon, Cambridge and the Turkish model) accurately predicted non-SN involvement in a North African Tunisian population. METHODS: During a five years period, we identified 87 cases of invasive breast cancer which had a positive SN biopsy and complete axillary lymph node dissection (CALND). The MSKCC, Stanford, Tenon, Cambridge and Turkish models were tested. Results were compared using the area under the curve (AUC) of the receiver operating characteristics for each model. False negative and false positive rates were also calculated. RESULTS: The AUC of the MSKCC, Stanford, Tenon, Cambridge and Turkish models was respectively 0.73 (95% CI 0.6-0.86), 0.76 (95% CI 0.65-0.87), 0.75 (95% CI 0.63-0.87), 0.67 (95% CI 0.53-0.82) and 0.75 (95% CI 0.63-0.88). The threshold for a 10% false negative of non-SN involvement was obtained with a cut off value of 10% for MSKCC, 25% for Stanford, a score of 3 for Tenon, 6% for Cambridge and 15% for the Turkish nomogram. CONCLUSIONS: Meaningfully applied to our population, although AUC values had overlapping of 95% confidence intervals but combined our data suggest that the Stanford nomogram may be the most accurate. Before prospective trials validate these nomograms, CALND remains the standard for patients who have SN metastases.

[Conserving surgery for breast cancer]. / Le Traitement Conservateur du Cancer du Sein.

Breast cancer is the first women's cancer. Conserving surgery associated with radiotherapy, is in progress. Her indications are frequent. The result for local control and global survival are the same as radical surgery.

Sentinel node biopsy in breast cancer: time has come to systematically perform it before planned axillary clearance.

Sentinel lymph node biopsy is a simple and relatively safe technique that emerged as a standard in the management of early breast cancer. Indications are becoming larger and because this particular node provides significant epidemiological, clinical, pathological, educational and prognostic information efforts must be done to identify it even when a a complete axillary clearance is planned.

Sentinel lymph node biopsy after neoadjuvant chemotherapy in inflammatory breast cancer.

BACKGROUND: Sentinel lymph node biopsy (SLNB) demonstrates promising results as an accurate alternative to axillary lymph node dissection in patients with locally advanced breast cancer after neoadjuvant chemotherapy (NAC). However and in the view of the insufficient data on women with inflammatory breast cancer (IBC), SLNB is not recommended in this situation. The current study assessed identification and false-negative rates of SLNB after NAC for patients with IBC. METHODS: Between 2006 and 2009, twenty consecutive patients with clinically negative nodes after NAC for IBC (T4d) and who underwent SLNB and axillary lymph node dissection (levels I and II) by the same operator were assessed. Intraoperative Sentinel lymph node biopsy was performed with patent blue dye injections. RESULTS: The SLN could be identified in 16 of 20 patients (identification rate, 80%), the median of SLN removed per patient was 2 (range 1-3); nine (56%) had positive SLNB, and in 2 of those 9 patients (22%), the SLN was the only positive node with otherwise negative axillary nodes. Two (18%) patients' SLNB were false negative. CONCLUSIONS: The SLN identification and false-negative rates after NAC for IBC were unacceptably high and based on the current findings, SLNB without systematic axillary lymph node dissection is unsuitable in this patient population.

[Recurrent hydatidiform mole. Case report of 9 successive molar pregnancies]. / La mole hydatiforme recidivante. A propos d'un cas avec 9 grossesses molaires successives.

The recurrent hydatiform mole is rare, its frequency is lower to 1%. We report the observation of a 28 years old women. without antecedents of molar pregnancy in the family and without considerable pathological antecedents. She had 9 successive molar pregnancies, without inset normal pregnancies and without living children. The delay of at least 1 year between the gestations has been respected in 6 pregnancies. The etiologic balance in particular the caryotypes of parents is normal. The authors debate the étiopathogénic and prognostic factors of this pathology.

[Epithelial advanced ovarian carcinoma in the central region of Tunisia: therapeutic results and prognostic factors on 104 patients]. / Les tumeurs épithéliales malignes évoluées de l'ovaire dans le centre tunisien: résultats thérapeutiques et facteurs pronostiques à propos de 104 cas.

Between 1994 and 2004, 104 patients with epithelial advanced ovarian cancer were treated in the central region of Tunisia (81 stage III and 23 stage IV). Average age of patients was 54 years. Primary surgery was optimal (residue < 2 cm) in 40 cases (38,5 % of patients). Fifty nine patients were treated with neo adjuvant chemotherapy based on platinum, associated to paclitaxel in 19 % of cases. Interval debulking surgery interested 30 patients and was optimal in 66,7 % of cases. Global survive was 57 % at 2 years and 27 % at 5 years. Survival rate for patients treated with optimal debulking surgery was similar to that of those treated with initial optimal surgery. Prognostic factors for a better survive were : age < 40 years (p < 0,05), stage III (p < 0,01), a normal level of CA125 after surgery (p < 0,01), primary optimal initial surgery (p < 0,02) and response to neoadjuvant chemotherapy (p < 0,01). Prognosis of ovarian carcinoma is worse in Tunisia as like as in the world. In case of extensive tumor, the neoadjuvant chemotherapy before interval debulking surgery permits to improve survive and quality of life in some patients.

[Ovary teratoma. Report of 91 cases]. / Teratomes de l'ovaire. A propos de 91 cas.

OBJECTIVE: To analyse the clinical and anatomic aspects of cystic teratomas of the ovary, caracteristics of patients having cystic teratomas and the management trends at our institution. STUDY DESIGN: Retrospective study of 91 cases of cystic teratomas of the ovary diagnosed and treated at Farhat -Hached Hospital (Sousse) between 1 january 1995 and 30 june 2003. RESULTS: Cystic teratomas constituted 12.13% of all ovarian tumors diagnosed and treated at our institution during the study period. The median of age was 33.35 ans. Abdominal or pelvic pain was the most frequent symptom for presentation in 67% of the cases. In addition; incidental finding was noted in 25.3% of the cases and swelling in 23% of the cases. The mean tumor diameter was 10 cm. The rate of bilateral cystic teratomas of the ovary was 14.3%. 19.8% of cystic teratomas has occurred in pregnancy. The operative video-laparoscopy was employed in 9 cases, laparotomy was employed in82 cases. Histopathological evaluation has detected 96.7% cases of mature teratomas, and 3.3% cases of immature teratomas. CONCLUSION: Cystic tertomas are the most common ovarian neoplasms, that occurs most commonly during the reproductive years. The operative laparoscopy is the most common modality of treatment of mature cystic teratomas. Immature teratomas must be treated by laparotomy associated if necessary to chimiothrapiy.

[Prognosis of local recurrence of breast cancer in Tunisia]. / Les recidives loco-regionales du cancer du sein dans le Centre Tunisien (etude anatomo-clinique et facteurs pronostiques).

OBJECTIVE: To evaluate locoregional recurrence rate of breast cancer, determine its anatomoclinical characteristies and discuss the available therapeutic alternatives. PATIENTS AND METHODS: A retrospective study including 41 patients with LRR following modified radical mastectomy or conservative surgery of invasive breast carcinoma without metastasis, between January 1993 and December 2002. RESULTS: 38 cases of LRR occurred after mastectomy and 3 cases after conservative surgery. LRR rate was 4.84%, mean follow-up 44.7 months. Mean age of patients was 45 years and LRR mean occurrence time-interval 22.4 months. Recurrence was parietal in 25 cases, mammary in 2 cases, and nodal in 14 cases. 18 patients had to be operated on. CONCLUSION: Prognosis of breast cancer depends on distant metastasis. LRR constitutes the second major risk liable to influence the overall prognosis.

[Knowledge, attitude and behavior about the inherited predisposition to cancer. A survery of a population without any history of cancer in central Tunisia]. / Connaissances, attitudes et comportements vis a vis de la predisposition hereditaire aux cancers. Enquete aupres d'une population indemne de cancers dans le centre Tunisien.

The genetic bases of inherited predisposition to cancer are now established. The aim of our study is to value the knowledge, attitude and behavior of the general population about the inherited predisposition to cancer. Our study involved a population of 200 individuals. Without any history of cancer. The mean age of our population was 37.5 years (18 to 74 years). The education level was low in 62.5% of cases (illiterate or primary education). About knowledge: heredity was considered a predisposing factor to cancer by 42.5% of the respondents. About attitude: we noted a cancerophobia in 82% of cases. 86.5% of our respondents trought that an early diagnosis increased the chance of recovery. About behavior: 72.5% of the studied population wishd to know if they were predisposed to develop cancer. In case of pregnancy, 79% wished to know if the foetus wasa cancer gene predisposition carrier. 28% would keep this foetus in case of positive genetic testing. These results are encouraging to develop oncogenetic counselling in Tunisia.

[Breast cancer in elderly women in Tunisia. Retrospective study of 106 patients older than 65 years]. / Le cancer du sein chez la femme âgée en Tunisie. Etude rétrospective à propos de 106 patientes de plus de 65 ans.

OBJECTIVE: To report the epidemiological profile, anatomo - clinic, prognostic and therapeutic of breast cancers in aged woman from the region of the Center of Tunisia. Our retrospective study concern 106 patients with mammary cancers treated between January 1990 and December 1997 at the Farhat Hached Hospital in Sousse (Tunisia). The mean age was 71 years (extremes 65-91), 66% of the patients had an age more than 75 years, the mean age at the menopause was of 50 years. The size middle clinic was of 50 mm, 45.3 % of tumors was classed T4, 39.6 % T3. 39.6% of patients have a clinical axillary adenopathis. 14.2% of patients have metastases at diagnostics. 62.5% of the cases have a high histo-pronostic grading. The prognostic factor analysis recovered in multivary survey two parameters significatifs for the survival: the size tumoral (p <0.005) and the presence of metastases at the time of the diagnosis (p <0.001). The biologic and evolutionary features of the cancer of the breast in the aged woman bring to consider the hormonal approach like the most logical, especially for the patients bearers of hormonosensibles tumors, of or the interest of the systematic dosage of the hormonal receptors.