Adjuvant management of operated uterine sarcomas: A single institution experience.

PURPOSE: The purpose of this study was to describe the adjuvant management of high grade uterine sarcoma and highlight prognostic factors for overall survival and progression-free survival. MATERIAL AND METHODS: Between 01/2000 and 01/2015, 91 patients undergoing surgery were presented at the multidisciplinary team meeting of our institution. The type of surgery, the anatomopathological features, adjuvant treatments, dates and sites of recurrence were collected. The prognostic value of the various factors was evaluated with the multivariate Cox model. RESULTS: A total of 50 women with uterine sarcoma were identified and lesions included 43 leiomyosarcomas (86%) and seven high grade sarcomas (14%). Eighteen patients received adjuvant pelvic radiotherapy (36%) and six adjuvant systemic therapy (12%). The median follow-up time was 63 months. Thirty-nine patients (78%) had a recurrence: 22 had only metastatic recurrence (58%), two had isolated pelvic recurrence (5%) and 15 had pelvic and metastatic recurrence (38%). Adjuvant radiotherapy was associated with survival without pelvic recurrence in univariate analysis (P=0.005, hazard ratio [HR]=0.15); age greater than 55 years and adjuvant radiotherapy were associated with metastatic free survival in multivariate analysis (P=0.015, HR=2.37, and P=0.013, HR=0.41 respectively) CONCLUSION: According to the results of our series, there is a benefit of radiotherapy after surgery in terms of local control of uterine sarcoma. It is necessary to identify the subgroup of patients who will benefit from an adjuvant radiotherapy in order to provide them with more optimal care.

Evaluation of patients' needs to design and assess a patient education program in cancer pain.

Purpose: Patient education constitutes a relevant strategy to improve pain management. In the field of therapeutic patient education (TPE), we aimed 1) to assess pain impact in cancer patients, 2) to identify patients' educative needs in pain management, and 3) to refine research criteria for its future evaluation. Patients and methods: Pain intensity, relief and interference were assessed in 75 cancer patients with unbalanced background pain. Self-assessment questionnaire evaluated i) patients' pain management and ii) their knowledge and needs in TPE. Results: Most patients experienced pain for more than 6 months and 41.6% reported adequate pain relief. Understanding pain and pain management were major patients' preferences (>58%). Most patients declared they knew their pain treatments, but fewer than half of them were able to name them. However, education concerning pain treatment was considered as essential in <30% of patients. Almost all patients (97.1%) stated pain education as beneficial, with a preference for individualized sessions (41.2%). In addition, the assessment criteria for its future evaluation were refined. Conclusion: Targeted population mainly concerned patients with persistent pain. Only half of patients reported pain relief despite antalgics. Patient education was declared as beneficial for almost all participants. Practice implications: Tailoring a pain TPE on patients' needs has the potential to help them to optimally manage their pain daily.

Assessment of medial coronoid disease in 180 canine lame elbow joints: a sensitivity and specificity comparison of radiographic, computed tomographic and arthroscopic findings.

BACKGROUND: Diagnostic imaging is essential to assess the lame patient; lesions of the elbow joint have traditionally been evaluated radiographically, however computed tomography (CT) has been suggested as a useful technique to diagnose various elbow pathologies. The primary objective of this study was to determine the sensitivity and specificity of CT to assess medial coronoid disease (MCD), using arthroscopy as gold standard. The secondary objective was to ascertain the radiographic sensitivity and specificity for MCD compared with CT. METHODS: For this study 180 elbow joints were assessed, of which 141 had been examined with radiography, CT and arthroscopy; and 39 joints, had radiographic and CT assessment. Sensitivity and specificity were calculated for CT and radiographic findings using available statistical software. RESULTS: Sensitivity and specificity of CT using arthroscopy as gold standard resulted in high values for sensitivity (100 %) and specificity (93 %) for the assessment of MCD. For the radiographic evaluation, a sensitivity of 98 % and specificity of 64 - 69 % using CT as the technique of reference, were found. DISCUSSION: These results suggest that in case of doubt during radiographic assessment, CT could be used as a non-invasive technique to assess the presence of MCD. CONCLUSION: Based on the high sensitivity and specificity obtained in this study it has been considered that CT, rather than arthroscopy, is the preferred noninvasive technique to assess MCD lesions of the canine elbow joint.

[Sensitivity and specificity of the breast screening program in the Isere region based on positive results between 1991 and 1999]. / Analyse de la sensibilité et de la spécificité des mammographies en fonction des taux de tests positifs dans le programme de dépistage organisé de l'Isère de 1991 à 1999.

PURPOSE: The screening program guidelines specify that the call back rate of women for additional imaging (positive mammogram) should not exceed 7% at initial screening, and 5% at subsequent screening. Materials and methods. Results in the Isere region (12%) have prompted a review of the correlation between the call back rate and indicators of quality (detection rate, sensitivity, specificity, positive predictive value) for the radiologists providing interpretations during that time period. RESULTS: Three groups of radiologists were identified: the group with call back rate of 10% achieved the best results (sensitivity: 92%, detection rate: 0.53%, specificity: 90%). The group with lowest call back rate (7.7%) showed insufficient sensitivity (58%). The last group with call back rate of 18.3%, showed no improvement in sensitivity (82%) and detection rate (0.53%), but showed reduced specificity (82%). CONCLUSION: The protocol update in 2001 does not resolve this problematic situation and national results continue to demonstrate a high percentage of positive screening mammograms. A significant increase in the number of positive screening examinations compared to recommended guidelines is not advantageous and leads to an overall decrease in the quality of the screening.

Sickness absence as a prognostic marker for common chronic conditions: analysis of mortality in the GAZEL study.

OBJECTIVES: To determine whether sickness absence is a prognostic marker in terms of mortality among people with common chronic conditions. METHODS: Prospective occupational cohort study of 13,077 men and 4871 women aged 37-51 from the National Gas and Electricity Company, France. Records of physician-certified sickness absences over a 3-year period were obtained from employers' registers. Chronic conditions were assessed in annual surveys over the same period. The main outcome measure was all-cause mortality (803 deaths, mean follow-up after assessment of sickness absence: 13.9 years). RESULTS: In Cox proportional hazard models adjusted for age, sex, socioeconomic position and co-morbidity, >28 annual sickness-absence days versus no absence days was associated with an excess mortality risk among those with cancer (hazard ratio 5.4, 95% CI 2.2 to 13.1), depression (1.7, 1.1 to 2.8), chronic bronchitis or asthma (2.7, 1.6 to 4.6) and hypertension (1.6, 1.0 to 2.6). The corresponding hazard ratios for more than five long (>14 days) sickness-absence episodes per 10 person-years versus no such episodes were 5.4 (2.2 to 13.1), 1.8 (1.3 to 2.7), 2.0 (1.3 to 3.2) and 1.8 (1.2 to 2.7), respectively. Areas under receiver operating characteristics curves for these absence measures varied between 0.56 and 0.73, indicating the potential of these measures to distinguish groups at high risk of mortality. The findings were consistent across sex, age and socioeconomic groups and in those with and without co-morbid conditions. CONCLUSION: Data on sickness absence may provide useful prognostic information for common chronic conditions at the population level.

Home and leisure injuries among the French electricity and gas company active employees: circumstances and short-term consequences.

OBJECTIVE: To characterize home and leisure injuries and their immediate consequences among adults aged 20-60 years and to look for homogeneous profiles of injury circumstances to assess the possibility of setting up prevention programs. DESIGN: Cross-sectional survey by questionnaire completed on the occasion of a medical visit after a first episode of absence for home or leisure injury between 1 January and 31 December 1997 among Electricité de France Gaz de France (EDF GDF) workforce of three geographical areas (47,681 employees). Incidence and relative risks according to sex, age and work grade and a multidimensional classification of injury circumstances. RESULTS: Eight hundred and fifty four injuries were studied. Risk was estimated at 18.4 injury victims per 1000 employees, of which 13.4 per 1000 employees were home injury victims and 3.7 leisure injury victims. The risk of all injuries was higher among men than women (RR=1.3) and decreased as work grade rose: for men, it was five times higher among operating employees than managers. Multidimensional analysis of injury circumstances ended by distributing into four main classes which may be useful for prevention: gardening and do-it-yourself injuries outdoors (19.9%), coming and going on the streets (6.9%), falling while coming and going in the home on the stairs (13.4%), and do-it-yourself inside the home (13.0%). Injuries induced essentially four types of lesions: sprains (34%), fractures (31.8%), contusions (24.5%) and wounds. The mean sick-leave lasted 32.1 days but half the subjects returned to work in less than 17 days. Hospitalization was necessary in 19.2% of cases. CONCLUSIONS: This study completed by an analysis of the behavioural factors of injuries led us to propose programs aimed at changing the risk behaviours related to do-it-yourself, stairs falls and gardening.

The Wip1 phosphatase (PPM1D) antagonizes activation of the Chk2 tumour suppressor kinase.

We previously demonstrated that type 2C protein phosphatases (PP2C) Ptc2 and Ptc3 are required for DNA checkpoint inactivation after DNA double-strand break repair or adaptation in Saccharomyces cerevisiae. Here, we show the conservation of this pathway in mammalian cells. In response to DNA damage, ataxia telangiectasia mutated (ATM) phosphorylates the Chk2 tumour suppressor kinase at threonine 68 (Thr68), allowing Chk2 kinase dimerization and activation by autophosphorylations in the T-loop. The oncogenic protein Wip1, a PP2C phosphatase, binds Chk2 and dephosphorylates phospho-Thr68. Consequently, Wip1 opposes Chk2 activation by ATM after ionizing irradiation of cells. In HCT15 colorectal cancer cells corrected for functional Chk2 activity, Wip1 overexpression suppressed the contribution of Chk2 to the G2/M DNA damage checkpoint. These results indicate that Wip1 is one of the phosphatases regulating the activity of Chk2 in response to DNA damage.

APRAND programme: an intervention to prevent relapses of anxiety and depressive disorders. First results of a medical health promotion intervention in a population of employees.

OBJECTIVE: The study sought to determine whether an organized health promotion intervention during medical consultations improves the outcome for patients who meet the ICD10 criteria for anxiety or depressive disorders. METHODS: In 2001, physicians used the MINI to screen 9743 employees on sick leave and consulting physicians in 21 medical centres of a large company. A health promotion intervention was implemented in eight "active" centres. It took place immediately after diagnosis and consisted of explaining the disorders, delivering the test results and leaflets based on WHO recommendations, and advising patients to consult their personal physician, psychiatrist or occupational physician, if necessary. Its effectiveness, evaluated by symptom severity and outcome over 1 year, was assessed by comparing the eight active centres to 13 control centres (without the intervention). RESULTS: Disorders were detected among 10.6% of the subjects, 29.4% of whom had no previous diagnosis of anxiety or depressive disorder. The intervention was associated with a positive effect on the 6-week and 6-month HAD scores. Total absence of disorders at 1 year was associated with age, sex, and intervention, among all identified cases (OR=1.53), among those with at least one anxiety disorder (OR=1.45), and among those with at least one depressive disorder (OR=1.40). CONCLUSION: Combining detection with organized provision of information including printed material improves patients' outcome and physicians' diagnostic abilities.

A case of stunning of lung and bone metastases of papillary thyroid cancer after a therapeutic dose (3.7 GBq) of 131I and review of the literature: implications for sequential treatments.

Thyroid stunning is usually defined as the inhibition or suppression of iodide trapping by remnant thyroid tissue or by functioning metastases following a diagnostic dose of 131I. The risk of stunning increases progressively with larger doses. Because the threshold above which this effect occurs in thyroid remnants seems to be between 37 MBq and 111 MBq of 131I, therapeutic 131I doses of 3.7 GBq may cause stunning. We describe stunning of papillary thyroid cancer lung and bone metastases after a therapeutic dose of 131I (3.7 GBq). A T1 bone metastasis and bilateral lung metastases were diagnosed by post-therapeutic dose whole-body scan. Nuclear MRI detected another lesion at T4, whose 131I fixation was not obvious. An additional 0.7 GBq were given after recombinant TSH, 37 days after the therapeutic dose; 24 h later, uptake by the lung and T1 metastases had disappeared, but trapping was again seen 6 months later on the post-therapeutic scan. This re-appearance is evidence in favour of the transitory and reversible character of stunning, and confirms its correspondence to the decreased ability of viable thyroid cells to trap iodine and not to their destruction. A better understanding of stunning would make it possible, in the event of rapidly progressing disease and in conjunction with recombinant thyroid stimulating hormone (TSH), to give several therapeutic doses of 131I in close succession without each dose hampering the effectiveness of the subsequent one.

[Initial or interval debulking surgery for advanced stage ovarian cancer: state-of-the-art. How to select patients?]. / Chirurgie initiale ou d'intervalle dans les cancers de l'ovaire de stade avancé? Etat de la question en 2004 et critères de sélection des patientes.

The management of advanced stage ovarian cancer has been deeply modified over the last few years. In patients with massive peritoneal spread, the use of neoadjuvant chemotherapy, followed by interval surgery, reduces the morbidity of radical surgery with an improvement of the quality of life. Nevertheless, results of ongoing randomized studies should be waited before stating about the results on survival of such management compared to initial debulking surgery. Waiting such results, the standard treatment of advanced stage ovarian cancer in 2005 remains initial surgery, performed in order to obtain ideally a total resection of all macroscopic diseases, and followed by adjuvant chemotherapy. However, in patients with massive spread, interval debulking surgery is becoming an interesting option, and will perhaps become a standard management. But criteria to select patients between initial and interval debulking surgery should be clearly defined. Those different points will be studied in this paper.

[Mortality among active workers at EDG-GDF: social and occupational disparities and evolution]. / La mortalité des salariés d'EDF-GDF: disparités socioprofessionnelles et évolution.

BACKGROUND: Two studies, conducted in the eighties and the nineties, reported that mortality was lower in the French national electric and gas company (EDF-GDF) the utility workers than in the general French population. The purpose of our study was to compare the mortality of these 140,000 utility workers to that of the French population of the same age for the period from 1997 to 2001. Secondly we aimed to assess the disparities of mortality among the workforce according to demographic and socioprofessional criteria. Finally, we analyzed the evolution of this mortality over the last twenty years. METHODS: We undertook a cross-sectional study using the indirect standardization method. RESULTS: Risk of death was lower in the utility workers than in the French population (SMR=54% for men, and 58% for women). These differences had increased over the last twenty years for each main cause of death (cancers, cardio-vascular diseases and accidents). The reported excess of brain cancer death risk raises etiologic questions. Moreover, we noticed important social disparities in the workforce, increasing with time. CONCLUSION: The well-known "healthy worker effect" seems to be particularly important in the EDF-GDF company. The workers have a high level of living conditions and good working conditions, although internal social disparities persist. Further studies in other large corporations are greatly needed for comparisons.

[Value of MRI in symptomatic patients treated with tamoxifen]. / Apport de l'IRM chez les patientes symptomatiques traitées par tamoxifène.

PURPOSE: To assess the MR imaging (MRI) findings in symptomatic tamoxifen treated-women with abnormal transvaginal sonography. PATIENTS AND METHODS: From january 1997 to june 2000, 32 consecutive symptomatic tamoxifen treated-women with abnormal transvaginal sonography were prospectively studied by MRI. T1-weighted, T2-weighted, post-contrast T1-weighted and dynamic gradient-echo T1-weighted sequences were used. All patients underwent uterine sampling within one month of MRI. RESULTS: Endometrial thickness at sonography ranged from 5 to 48 mm (mean thickness 19 mm), and on T2-weighted imaging ranged from 3 to 50 mm (mean=25 mm). Three MRI patterns were found. Pattern 1 (13 patients) was defined as homogeneous high signal intensity of the endometrium on T2W images, and signal void in the lumen on gadolinium-enhanced images. Pattern 2 (8 patients) was defined as heterogeneous endometrial signal on T2W images, and latticelike enhancement traversing the endometrial canal on gadolinium-enhanced images. Pattern 3 (11 patients) was defined as heterogeneous signal on T2W images with masses or nodules which were better seen on dynamic gadolinium-enhanced images. In pattern 1 we found 13 atrophic endometrium, in addition there were 4 polypoid glandulo-cystic proliferation (PGCP), and 1 adenomyosis. In pattern 2 we found 3 PGCP, 4 atrophy and 1 polyp without hyperplasia. The 2 carcinomas and the polyps with hyperplasia were found in pattern 3 (11 patients). CONCLUSION: In our experience MRI allows differentiation of lesions which may require surgery from other lesions in which noninvasive follow-up is possible.

Epidemiological surveillance at Electricité de France-Gaz de France: health assessment of nuclear power plant employees between 1993 and 1998.

Because the 17,500 employees working in nuclear power plants at Electricité de France, the national power company, may be exposed to a wide variety of industrial hazards, the health insurance department of the company has set up an epidemiological surveillance programme for them. This report describes its first stage, an analysis of their health problems. This descriptive, cross-sectional and exhaustive study examined sick-leave, mortality and cancer incidence to assess the health of the employees working from 1993 through 1998. The analysis compared the employees in nuclear power plants, considered 'exposed', with the rest of the personnel of Electricité de France-Gaz de France, the 'non-exposed' (125,000 persons). Relative risks for these variables were estimated, after stratification for age, sex and work grade. Globally, the employees in the nuclear sector appeared to have fewer health problems than the other company employees. This was true regardless of age and especially for men, operating employees and supervisory employees. Nonetheless, three points must be noted: non-work accidents generated a non-significant excess of absenteeism and mortality among these employees, especially among management and supervisory personnel; suicides affected supervisors in particular; and an excess of primary malignant brain tumours affected both mortality [relative risk (RR) = 1.96, n.s.] and incidence, especially among operating employees (RR = 2.87, 95% confidence interval = 1.00-8.43). No excess of malignant blood disease was observed. This study, performed for surveillance purposes, points to brain tumours as a problem that raises important aetiological questions. Research is now necessary to provide answers. Surveillance of nuclear plant employees at Electricité de France should be continued and expanded to include the study of specific occupational exposures.

Socioeconomic, demographic, occupational, and health factors associated with participation in a long-term epidemiologic survey: a prospective study of the French GAZEL cohort and its target population.

The purpose of this paper is to examine personal and health factors, both at the beginning of the study and thereafter, associated with participation in the GAZEL cohort, set up in 1989 in a large French company. The authors used logistic regression to analyze the associations between participation and data available for both participants (n = 20,093) and nonparticipants (n = 24,829). Higher participation was associated with male sex, marriage, children, managerial status, and residence in particular regions. Among men, lower participation was associated with sick leave in the year before recruitment and afterwards. During follow-up, participation was negatively associated with several groups of diseases, especially those associated with alcohol consumption. The risk of upper respiratory and digestive tract and lung cancer during follow-up was higher among nonparticipants. The same phenomenon occurred among women, but less markedly, for cancers of the breast and genital organs. During follow-up, mortality among men was higher among nonparticipants, especially for alcohol-related diseases. The association among women was less strong. Among men, but not among women, diseases caused by alcohol, smoking, or dangerous behavior were the primary reason for the health differences observed between participants and nonparticipants. Overall, the most important determinants of participation were cultural factors and lifestyle behaviors.

Surgical staging of early invasive epithelial ovarian tumors.

Early stage epithelial ovarian carcinoma is defined pathologically as a tumor strictly limited to one or both ovaries without any extra-ovarian disease (i.e., Stage IA or B of the International Federation of Gynecology and Obstetrics (FIGO) classification). This diagnosis can be obtained only after an exhaustive surgical staging procedure, performed as soon as the diagnosis of epithelial invasive ovarian carcinoma is established. This staging surgery currently encompasses a peritoneal cytology, the thorough inspection of all the visceral and parietal peritoneal surfaces with biopsy of any abnormality, total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH + BSO), random peritoneal biopsies, omentectomy, appendectomy and bilateral pelvic and para-aortic lymphadenectomies, up to the left renal vein. The results of this staging procedure and its indications are discussed. In all of the cases, the radical removal of the pathologic adnexa is indicated, along with the complete peritoneal and retroperitoneal staging. While fertility-sparing surgery (avoiding hysterectomy and contralateral adnexectomy, if possible) seems to be safe for young women, a TAH + BSO is the rule for the others. Adjuvant chemotherapy can be omitted in well-differentiated tumors with a negative staging operation, but currently it remains indicated in all other cases. Indeed, the ultimate goal in early stage ovarian carcinoma is to not impair by inadequate management the high chance of a cure.

[Role of laparoscopy in the management of uterine cervix cancer]. / Rôle de la coeliochirurgie dans la prise en charge des cancers du col utérin.

At the turn of this century, the evidence of the benefits of a concurrent chemo-radiotherapy in locally advanced tumors and the development of mini-invasive surgery (laparoscopic and radical vaginal surgery) are the two main advances in the management of cervical carcinomas. From a personal experience of 304 cervical carcinomas, the different techniques of laparoscopy used in cervical carcinomas are addressed and discussed. Their long-term results when involved in the management protocols of cervical carcinomas at different stages are reported. From this series, some conclusions are drawn: 1) laparoscopy can spare a laparotomy in early-stage node-negative patients with low tumoral volume; 2) it can spare a systematic extended-field radiation therapy in high-risk patients with node-negative para-aortic exploration; 3) it can spare surgery in patients with a centro-pelvic advanced stage or recurrence, possibly candidates for an exenterative procedure, if occult spread is found in the intra- or retroperitoneal areas. The more and more frequent combination of the mini-invasive surgery for staging and treatment and radiotherapy or chemotherapy explains the need for new protocols of a more and more complex and specialized management.

Occupational risk factors for lung cancer in the French electricity and gas industry: a case-control survey nested in a cohort of active employees.

The main aim of this study was the analysis of occupational lung cancer risk factors in the French national electricity and gas company (Electricité de France-Gaz de France (EDF-GDF)). A case-control survey nested in a cohort of male employees was undertaken. The study population consisted of all male staff who were active at EDF-GDF between January 1, 1978, and December 31, 1989. During this period, 310 cases of lung cancer were identified in the cancer register set up by the medical department of the company. For each case, four age-matched controls who were free of cancer at the time of occurrence of the case's lung cancer were randomly selected. Occupational exposures to 21 chemical agents were assessed for each subject using a job exposure matrix. The associations between lung cancer and the different agents were estimated using conditional logistic regression analysis. After adjustment for various occupational confounding factors, the analysis showed increased lung cancer risks linked to exposure to crystalline silica (highest exposure class: odds ratio = 2.27; 95% confidence interval: 1.10, 4.68) and creosotes (highest exposure level: odds ratio = 2.14; 95% confidence interval: 1.06, 4.31), with significant dose-response relationships for both exposures.