[Revision of the French colposcopic terminology]. / Nouvelle classification française des images colposcopiques.

OBJECTIVES: To revise the 1983 colposcopic terminology form the French Society of Colposcopy and cervicovaginal pathology (SFCPCV). METHODS: All the three following steps of colposcopic examination were considered for the description of various colposcopic features: inspection without coloration, followed by the application of acetic acid and iodine staining. This revised terminology now includes the different possible colposcopic aspects of the normal cervix, including the ectropion and the normal transformation zone. It also includes colposcopic appearance of abnormal glandular cervical epithelium and of vaginal epithelium. The revised nomenclature was reviewed by all the board of the SFCPCV and was finally approved during the 45th annual conference of the SFCPCV. RESULTS: Abnormal transformation zone grade (TAG) 1a and 1b have been brought together under the sole TAG1 designation. TAG2a and TAG2b now correspond to TAG2, whereas TAG2c corresponds to TAG3. Colposcopic report should mention the interpretability of the colposcopic examination, with the precise type of the squamocolumnar junction (1, 2 or 3), the colposcopic impression, the size of any TAG and finally mention whether one or multiple biopsies were taken and their precise location. Colposcopic impression must give priority to the most pejorative colposcopic aspect which takes precedence over others. CONCLUSION: When performing colposcopy, one should keep in mind that this examination only relies on the interpretation of various colposcopic signs and images with this not guaranteeing for diagnosis. Only histological analysis of a possible guided cervical biopsy provides for a precise diagnosis.

[IBD and pregnancy: From conception to birth]. / Maladie chronique inflammatoire de l'intestin et grossesse : de la conception à la naissance.

Inflammatory Bowel Diseases (IBD) are chronic conditions affecting young people in their reproductive age. Patient misinformation can be responsible for a self-imposed infertility as well as a suboptimal observance during pregnancy. The aim of this work was to review the influence of IBD and pregnancy on one another at each gestational stage and according to current literature. IBD activity is a major influential factor. In case of a well-controlled IBD, fertility won't be affected and pregnancy will take place without increase risk of complications. With the exception of thalidomide and methotrexate, most of treatments used in IBD are compatible with pregnancy and breastfeeding. Each flare should be optimally managed. Vaginal delivery is a safe option except for patients with active anoperineal lesions. Cesarean section should be systematically discuss in patient with ileal pouch-anal anastomosis.

[Contribution of array CGH in the management of fetal nuchal translucency]. / L'apport de l'ACPA dans la prise en charge des hyperclartés nucales.

OBJECTIVES: Increased nuchal translucency and cystic hygroma have a neonatal prognosis, when the karyotype is normal, which depends on the findings during the medical follow-up. Array comparative genomic hybridization (aCGH) has been systematically included in this follow-up by prenatal diagnosis teams. There are no guidelines and little information on the advantages of carrying out this test systematically. The aim of our study is to evaluate the contribution of the aCGH in the medical follow-up. METHODS: Fifty-one patients were included during 18 months and followed till the end of their pregnancy in prenatal diagnosis centers in Brest and Amiens. Inclusion criterion was a nuchal translucency above 3,5mm on the first trimester ultrasound. A fetal DNA ChromoQuant and aCGH analysis on chorionic villi sampling, and an ultrasound at 18 weeks of gestation were performed during the follow-up. RESULTS: The aCGH was decisive in only 2 cases. The ultrasound at 18 weeks gestation seemed to be more sensible in the detection of an abnormality. When the aCGH relieved an abnormality, the ultrasound permitted already to detect the presence of a deformity. In 10 cases, the aCGH could not be interpreted on the chorionic villi sampling. In 9 cases, an amniocentesis was performed in order to obtain this result. CONCLUSION: Given the results of this study, the aCGH was rarely determinant or decisive on the realization of a therapeutic abortion. These elements make us reflect on the necessity of maintaining this test before 14 weeks of gestation or propose it as a second-line test after the ultrasound shows signs at 18weeks of gestation.

[Correlation between prenatal and postnatal observations in case of gastroschisis: Experience in a prenatal referral diagnosis center]. / Corrélation des données anténatales et postnatales en cas de laparoschisis : expérience d'un CPDPN.

OBJECTIVES: Ultrasonography plays a key role in surveillance of gastroschisis. Indeed, ultrasound should allow an early diagnosis of its specific complications all the while avoiding their over-diagnosis which could induce an unnecessary prematurity in these fragile children. The aim of this study was to evaluate the relevance of ultrasonography in the surveillance of this malformation. METHODS: We conducted a retrospective single center study from 2008 until 2018 including all cases of apparently isolated gastroschisis followed during the prenatal period and surgically treated in our institution. Prenatal data gathered during the ultrasound follow-up were compared to those observed during surgery. RESULTS: Thirty-one cases of gastroschisis were included. Regarding the abdominal wall defect, the latter was described prenatally as tight in seven cases with a weak correlation, and as situated to the right of the umbilical cord insertion in 11 cases with a high correlation to the per-operative observations. Sonographic observations were responsible for inducing birth in 14 cases (45%), of which 12 due to the presence of a specific gastroschisis complication, confirmed in five cases (42%, weak correlation). Pre- and post-natal correlation for compression/atresia/stenosis and eviscerated bowel inflammation were very weak in both cases, with a respective tendency of over- and under-diagnosis. CONCLUSIONS: Diagnosing the specific complications of gastroschisis by ultrasound is difficult, even though ultrasonography is responsible for many anticipated births. Thus, this monitoring should be performed by experienced sonographers on devices with appropriate settings. In addition, reproducible parameters such as oligohydramnios or increased bowel dilations should alone be indications of anticipated birth.

The impact of using electrical impedance spectroscopy (ZedScan) on the performance of colposcopy in diagnosing high grade squamous lesions of the cervix.

OBJECTIVES: To determine the efficacy of colposcopy plus ZedScan, which measures changes in tissue electrical impedance, for detecting intraepithelial high-grade lesions compared to colposcopy alone. METHODS: A prospective study conducted at a university hospital colposcopy clinic. Patients referred following abnormal cervical cytology or colposcopic follow up were examined by colposcopy plus ZedScan to assess the cervix. The results of ZedScan directed and colposcopically directed biopsies were compared. RESULTS: Ninety-one patients were included in this study. The median age was 33 years. Eighty (88%) were referred with abnormal cytology; LSIL 45%, ASCUS 27%, ACS-H 8%, HSIL 7%, AGC 1% and 12% follow-up postconisation or colposcopic follow up. Colposcopy alone detected 18 high-grade lesions with 64 women undergoing biopsy with a total of 115 biopsies being taken with a sensitivity of 60% and NPV estimated at 81.7%. ZedScan with colposcopy increased the detection of high-grade lesions by 47.3%, identifying 27 high-grade lesions and one case of invasive cancer. Sensitivity was 93.1% and NPV estimated at 91.3%. A combination of normal colposcopy practice and ZedScan had a sensitivity and NPV of 100%. CONCLUSION: ZedScan used in conjunction with the colposcopy improves sensitivity in detecting high-grade lesions at the expense of a moderate increase in the number of biopsies.

Impact of anaesthesia mode on evaluation of LEEP specimen dimensions.

OBJECTIVES: To study the influence of anaesthesia (local by cervical block vs. general or spinal anaesthesia) on height and volume of resection specimens in case of conization treatment for cervical intraepithelial neoplasia (CIN). METHODS: Prospective observational study of all patients who underwent a first treatment by loop electrosurgical excision procedure (LEEP) for CIN. Height of fresh resection specimens was first measured by the operator and then by the pathologist after formaldehyde fixation. Volume of fresh specimens was measured in a measuring cylinder by fluid displacement. RESULTS: One hundred patients were included and 35% of LEEP were performed under local anaesthesia. There was a significant difference in height of specimens depending on anaesthesia mode: after fixation, the average height was 11.2mm in the general or spinal anaesthesia group vs. 8.8mm in the local anaesthesia group (P=0.002). There was also a difference in terms of volume depending on anaesthesia mode: 1.6mL in local anaesthesia group vs. 2.3mm in general and spinal anaesthesia group (P=0.01). CONCLUSIONS: Anaesthesia mode has an impact on height and volume of LEEP specimens. In our experience, local anaesthesia could reduce LEEP specimen height.

[Giant mesocolic cystic lymphangioma: A treacherous prenatal presentation. Case report]. / Lymphangiome kystique géant du mésocôlon : un diagnostic anténatal difficile. À propos d'un cas.

Cystic lymphangiomas are usually located in the neck region. Less frequently, they can be found in the abdomen. In those cases, pre- and neonatal diagnosis is extremely difficult. We report on the case of a giant mesocolic cystic lymphangioma, diagnosed at birth, in a child who had been monitored during the prenatal period for what was believed to be a digestive dilatation. The progression was marked by excellent tolerance despite a complete lack of regression in the first 10 months of life. The authors discuss the prenatal signs that should suggest this diagnosis and an MRI, as well as management during the 1st year of life.

[Granulosa cell tumor: difficulty of diagnosis and contribution of imaging]. / Tumeur de la granulosa : difficultés diagnostiques et apport de l'imagerie.

Granulosa tumors (GT) are rare neoplasms, difficult to diagnose in a preoperative stage. We report a set of seven patients affected by GT admitted in Amiens University Hospital, collated with a review of the literature (n=379). Our aim was to report the clinical and radiological characteristics of GT, in order to improve preoperative diagnosis. The average age of the subjects was 50.8 years old among the bibliographical search, and 37years old for the observations reported in Amiens. The principal circumstances of diagnosis were vaginal bleeding, abdominal pain and infertility. Ultrasound was the most frequently investigation, revealing GT as a large unilateral solid and cystic mass. The computed tomodensitometry (CT) allowed to precise the locoregional extension. Magnetic Resonance Imaging (MRI) appeared to be interesting to clarify lesions, showing GT as a solid mass with a cystic component or as a multicystic mass. Hormonal assays (inhibin B and/or anti-Müllerian hormone) can provide valuable assistance in diagnosis, despite their cost and lack of availability. In view of the clinical and radiological presentation of the reported and literature review cases, we suggest hormonal assays among perimenopausal women presenting with an unusual radiological aspect of an annexial mass.

[The conflict between obturator nerve and ovary: a cadaveric and radioanatomic study]. / Le conflit ovaro-obturateur : une étude cadavérique et radio-anatomique.

The aim of this study was to describe the anatomical relationships between the ovary and the obturator nerve in its intrapelvic portion. Seven embalmed cadavers were dissected; 20 MRIs were then analyzed. The main distance between the lateral pole of the ovary and the obturator nerve was 29 mm. The authors describe various etiologies responsible for obturator neuralgia. An underdiagnosed cause is gonadal hypertrophy.

[Vulvar cancer: survey of surgical practice in France. Do expert centers need?]. / Cancer de la vulve: enquête de pratique de la prise en charge chirurgicale en France. Faut-il se diriger vers des centres de références ?

OBJECTIVE: Vulvar cancer is rare. In France, surgical management of this cancer is codified by national guidelines. The aim of this survey was to evaluate its surgical management regards to the French guidelines. MATERIALS AND METHODS: Six hundred questionnaires were given to surgeons during two French congress in 2009. They focused on the surgeon (age, sex, occupation, center of work, practice of vulvar surgery, number of cancers treated individually and in the center), and the disease (initial work-up, surgical management and adjuvant therapy). Three case reports were also proposed, related to vulvar cancer management. RESULTS: Seventeen percent of surgeons (n=102) answered the questionnaire. Only half of them (52.9%) managed vulvar cancer. Of them, 83.2% reported treated less than five cancers per year; 87.4% of centers treated less than 10 vulvar cancers per year. Only 8.7% of surgeons respected the guidelines for the three case reports. The compliance rate was 80.5% for case A; 63.7% for case B and 22.5% for case C. No difference in answers' conformity to the guidelines was found according to age of surgeons, experience, workplace, number of cancers treated per year and centers. CONCLUSION: Despite some limits of our study, it appears that vulvar cancer management is often not conform to the French guidelines raising concerns on their insufficient diffusion and creation of expert centers.

[Uterine arteriovenous malformations: diagnosis and treatment in 2011]. / Diagnostic et traitement des malformations artério-veineuses utérines (MAVU) en 2011.

Uterine arteriovenous malformations (UAVM) are rare. They mostly occur after endo-uterine trauma, or are less often congenital. When symptomatic, they may be a cause of uterine recurrent and massive bleeding. Diagnosis should be evoked in these cases, to avoid haemostatic curettage which will be useless and injurious. UAVM is often suspected by Doppler ultrasound, but pelvic MRI seems to be also relevant. Angiography confirms the diagnosis and allows concomitant embolization. Uterine embolization seems to be currently the best treatment, however surgery should still be performed in case of failure or hemodynamic instability. In this work, we aim to evaluate diagnosis and therapeutic modalities for UAVM.

[Do there still exist risk factors for breast cancer?]. / Existe-t-il encore des facteurs de risque de survenue d'un cancer du sein ?

OBJECTIVES: To evaluate the risk factors associated with a breast cancer, and to compare the proportion of women at high and low risk for developing breast cancer. PATIENTS AND METHODS: Retrospective study among 194 women with breast cancer between January 2007 and December 2008 in the Obstetrics, Gynaecology and Reproductive Medicine department of the Amiens' University hospital. RESULTS: Concerning all the series, only age, overweight and family antecedents seem risk factors of breast cancer. The proportion of women in the low-risk group (12.3%) is not significantly different from that of the high-risk group (18.5%). In the low-risk group, the factors which seem to influence a breast cancer are those in connection with high levels of estrogens (early age of the first menstruation, late age of the menopause and oral contraceptive use) and the smoke habitus; whereas in the high-risk group, the factors are the nulliparity and the absence of breast feeding. DISCUSSION AND CONCLUSIONS: One finds in this series a part only of the known risk factors of breast cancer; and the proportion of women at low risk (12.3%) is comparable with that at high risk (18.5%). This study shows the relative weight of the various risk factors of breast cancer, at a time when its prevalence reached 10%.

[Intrauterine fetal death in a woman with a gastric banding]. / Mort fœtale in utero chez une femme porteuse d'un anneau gastrique.

Obesity defined by a Body Mass Index (BMI) over 30 is a major public health problem. Its correction may require surgical treatment in case of failure of adequate medical care. A pregnancy achieved in the aftermath of this surgery must be planned and monitored as a high-risk pregnancy, in fact it can complicate. We report here the occurrence of fetal death in a patient with a gastric banding.

[Should CIN 2 and 3 be treated the same way?]. / La CIN 2 merite-t-elle la même prise en charge que la CIN 3 ?

Although spontaneous regression of cervical intraepithelial neoplasia type 2 (CIN 2) occurs in 40% of cases over a 2 years period, such diagnosis commonly requires the use of excisional techniques exposing to genuine obstetrical and neonatal morbidity as well as the risk of unsatisfactory post-treatment colposcopy. Recent advances in knowledge about CIN 2 natural history and morbidity of conservative therapies brings out the need to optimize therapeutics indications and to reconsider the use of ablative techniques. In order to allow for the lack of histological analysis and final diagnosis, it is therefore crucial not to misdiagnose microinvasive cervical disease. The use of factors significantly related to the risk of microinvasion misdiagnosis allows for a simple and reliable risk assessment in decision-making regarding CIN 2 management. Thus, CIN 2 therapeutic abstention with simple follow up as well as ablative technique might be safely considered in women under 30 whose lesion involves only one cervical quadrant, with type one transformation zone, without any colposcopic sign of severity and whose cervical smear and biopsy results are concordant. Use of ablative techniques will be recommended in all other cases. If necessary, practice of large loop excision of the transformation performed under colposcopic vision by experienced practitioner should be preferred to all other excisional techniques.

[Modern management of cervical intraepithelial neoplasia: a proposal for a risk assessment method in colposcopic decision-making]. / Repenser la prise en charge des néoplasies intraépithéliales du col de l'utérus: proposition d'une méthode d'évaluation du risque et d'aide à la décision thérapeutique.

Recent improve in the understanding of the natural progression of cervical intraepithelial neoplasia (CIN) and in the knowledge of treatments pregnancy related morbidity in addition with progression in mean age of first pregnancy brings out the need to rethink CIN management. Efficient tools are therefore needed to optimize therapeutic indications and destructive techniques have to be reconsidered. Because there is no superior technique for treating CIN in terms of treatment failure, the choice of a treatment method will not depend on this criteria but on the overall consideration of its characteristics, advantages and limitations put in balance with age of women, plan of pregnancy as well as CIN severity, risk of progression and of microinvasion misdiagnosis. The use of a "risk assessment method" based on five criteria: colposcopic impression, transformation zone type and size, age and agreement between cytology and histology would allow for proper evaluation of the risk of microinvasion misdiagnosis. Depending on their severity, each of these five criteria would be graded from 1 to 3. The presence of at least one grade 3 criteria would warrant the need for excisional treatment, preferably large loop excision of the transformation zone, allowing for histological analysis and reliable diagnosis. Ablative technique could be reasonably considered for only one grade 2 criteria or if all criteria are grade 1, reflecting good prognosis. Such risk assessment method requires to be prospectively evaluated.

Clinical practice guidelines on menorrhagia: management of abnormal uterine bleeding before menopause.

BACKGROUND: Normal menstrual periods last 3-6 days and involve blood loss of up to 80ml. Menorrhagia is defined as menstrual periods lasting more than 7 days and/or involving blood loss greater than 80ml. The prevalence of abnormal uterine bleeding (AUB) is estimated at 11-13% in the general population and increases with age, reaching 24% in those aged 36-40 years. INVESTIGATION: A blood count for red cells+platelets to test for anemia is recommended on a first-line basis for women consulting for AUB whose history and/or bleeding score justify it. A pregnancy test by an hCG assay should be ordered. A speculum examination and Pap smear, according to the French High Health Authority guidelines should be performed early on to rule out any cervical disease. Pelvic ultrasound, both abdominal (suprapubic) and transvaginal, is recommended as a first-line procedure for the etiological diagnosis of AUB. Hysteroscopy or hysterosonography can be suggested as a second-line procedure. MRI is not recommended as a first-line procedure. TREATMENT: In idiopathic AUB, the first-line treatment is medical, with efficacy ranked as follows: levonorgestrel IUD, tranexamic acid, oral contraceptives, either estrogens and progestins or synthetic progestins only, 21 days a month, or NSAIDs. When hormone treatment is contraindicated or immediate pregnancy is desired, tranexamic acid is indicated. Iron must be included for patients with iron-deficiency anemia. For women who do not wish to become pregnant in the future and who have idiopathic AUB, the long-term efficacy of conservative surgical treatment is greater than that of oral medical treatment. Placement of a levonorgestrel IUD (or administration of tranexamic acid by default) is recommended for women with idiopathic AUB. If this fails, a conservative surgical technique must be proposed; the choices include second-generation endometrial ablation techniques (thermal balloon, microwave, radiofrequency), or, if necessary, first-generation techniques (endometrectomy, roller-ball). A first-line hysterectomy is not recommended in this context. Should a hysterectomy be selected for functional bleeding, it should be performed by the vaginal or laparoscopic routes.

[Endometrial cancer: survey of surgical practice in france in 2008]. / Cancer de l'endomètre. Enquête sur les pratiques chirurgicales en France en 2008.

OBJECTIVES: Endometrial cancer is the most common gynecologic malignancy. We aimed to assess the management of this disease among French surgeons as regards to the French guidelines. MATERIALS AND METHODS: Six hundred questionnaires were given to surgeons during two national French Meetings in 2008. They focused on the surgeon (age, gender, center of work, number of treated cancers individually and in the center) and on the disease (initial work-up, surgical management). Three case reports related to endometrial cancer were proposed to assess the conformity of the French guidelines (two case reports about endometrioid carcinomas stages IB and II and one about serous papillary adenocarcinoma). RESULTS: Nineteen percent of surgeons (n=114) answered the questionnaire. The French Guidelines were respected in less than 60 % in the answers of the three case reports (only 13.3 % of the answers were conformed in all the three cases). The surgeons who respected the recommendations took care of more than five treated patients per year (92.9 % versus 57.8 %, P=0.01), they were younger (41 year versus 49 years, P=0.01), and the post-graduation delay was shorter (9.1 versus 20.5 years, P=0.002). The center where the surgeon worked was not a determinant factor for treatment. The surgical procedures were mostly transverse laparotomy in 35.4 %. Peritoneal cytology and lymphadenectomy were provided in 69.9 % and 74.7 % of cases, respectively. CONCLUSION: Despite the limits of our study based on volunteer answers of surgeons to a questionnaire, our results highlight the efforts of learned societies and medical authorities should be used to standardize the treatment of cancer. A reflection should be conducted on the basis of initial training and throughout a professional career to provide patients optimal care of their pathology.