[How did I contract human Papillomavirus (HPV)?]. / Papillomavirus humain (HPV) : comment ai-je attrapé ça ?

More than 120 genotypes have been identified among the Papillomavirus (HPV) family. These viruses are ubiquitary with skin or mucous membrane tropism and cause various pathologies from wart to neoplasia. HPV family is classified according to their tropism. Genital HPV infection is considered as the most frequent sexually transmitted disease in the world. Seventy-five percent of women will be in contact with HPV at least one time in their life. HPV is usually transmitted through direct skin-to-skin contact, more often during penetrative genital contact. Other types of genital contact in the absence of penetration can lead to HPV infection, but those routes of transmission are much less common than sexual intercourse. However, virgins (<2 % of cases) and young children can present HPV infection, suggesting other routes of transmission than sexual intercourse. HPV infection could occur during delivery; vaginal deliveries appear to promote this transmission in comparison with cesarean section. But cesarean section do not completely protect against contamination risk. In utero, vertical transmission has been suggested by different studies but with lack of evidence. HPV infection can be detected on inanimate objects, such as clothing or environmental surfaces. However, transmission is not known to occur by this route. More detailed knowledges of the transmission route of HPV infection will enable to get prevention more effective.

[Cervical screening: toward a new paradigm?]. / Un nouveau paradigme pour le dépistage du cancer du col utérin?

OBJECTIVES: Analysis of the trials which compare the virologic testing (HPV testing) and the cytology in the cervical screening. MATERIAL AND METHODS: The MedLine database was consulted using the Keywords: "cervical screening", "pap smear", "liquid based cytology", "HPV testing", "adults", "adolescents", "cervical intraepithelial neoplasia (CIN)", "uterine cervix cancer". Articles were selected according their concern about the debate of the uterine cervix cancer screening in France. RESULTS: The HPV testing seems interesting allowing a decreasing delay in the diagnosis of CIN (more diagnosis of CIN2+ in the first round and less during the second one). But, when the two rounds are added, the number of CIN2+ are identical in the two arms (cytology and HPV testing) in all the trials (except the Italian NTCC trial). A negative HPV testing protects the women much longer than cytology can do: a delay of five years between two rounds seems ideal. The HPV testing alone increases the detection rate of cervical lesions, which could regress spontaneously and may induce an overtreatment, especially in the youngest population: a triage is necessary and the cytology appears to be the best way to select the candidates for colposcopy in case of positive HPV testing and cytology. The HPV infection presents some particularities in adolescent females: for this reason, the HPV testing should not be used in this special population. In vaccinated women, a consensus for the screening is necessary. CONCLUSION: The health care providers in France have to understand the characteristics of the HPV testing: its advantages compared to the cytologic screening are only evident in case of an organization of the screening in France and even in Europe.

[Pregnancy after uterine-artery embolization for symptomatic fibroids: a case of placenta accreta with uterine rupture]. / Un cas de rupture utérine sur placenta invasif compliquant une grossesse après embolisation des artères utérines pour fibromes.

The evolution of pregnancies following uterine-artery embolisation (UAE) for symptomatic fibroids remains uncertain. We report a case of pregnancy after UAE, complicated of adherent placenta with uterine rupture, in a context of uterine leiomyomata with a prior cesarean delivery. Through a recent review of the literature, we discuss the main obstetrical complications following UAE. Appropriate management of these high-risk pregnancies, notably in case of risk of adherent placenta, seems to be necessary.

[Persistence and recurrence of in situ cervical adenocarcinoma after primary treatment. About 121 cases]. / Persistance et récidive des adénocarcinomes in situ après traitement: à propos d'une série rétrospective multicentrique de 121 cas.

OBJECTIVE: The aim of this study is to assess the results of conservative management of adenocarcinoma in situ (AIS) of the uterine cervix. PATIENTS AND METHODS: Retrospective multicentric study with 121 cases. Patients with cervical invasive lesions were excluded. General characteristics of population, diagnosis circumstances, treatment, histology and evolution were studied. RESULTS: Conservative treatment was performed in 98.3% of cases with 64% of negative margins. In the positive margins group, 80% of conservative treatments were performed by electrosurgical loop. Length of cone resection is significantly higher for conization with negative margins (p<0.001). The rate of residual lesion was 18% in negative margins group and 46% in positive margins group. Two noninvasive and one invasive recurrence were deplored. DISCUSSION AND CONCLUSION: Conservative surgery for patients with AIS could be considered in young patients but several conditions should be respected: careful follow-up after conservative treatment; cold knife conization; length of cone specimen greater than 25 mm and negative margins.

[Vulvar invasive squamous cell carcinoma and hidradenoma papilliferum. Case report]. / Carcinome épidermoïde et hidradénome papillifère vulvaire. A propos d'un cas.

We report a case of a vulvar invasive squamous cell carcinoma associated to a benign tumor with apocrine differenciation, the hidradenoma papilliferum, infiltrated by the carcinoma. Diagnosis was established by clinical and histopathological examination, first on biopsy and then on local vulvar excision. Classical association between hidradenoma papilliferum and Paget's disease is described, but to the best of our knowledge, there have been no previous reports of such case in published literature. A common physiopathological etiology cannot be completely excluded.

Prenatal diagnosis in monozygotic twins with Down syndrome who had different phenotypes.

We report the case of monozygotic (MZ) male twin fetuses with different Down syndrome (DS) phenotypes. Prenatal fetal sonography showed a bichorial biamniotic pregnancy with increased nuchal translucency in twin A and a cervical cystic hygroma and heart defect in twin B. Cytogenetic analysis performed after double amniocentesis showed free and homogeneous trisomy 21 in both twins. Monozygosity was confirmed by molecular analysis. The pregnancy was terminated at 17 weeks of gestation (WG). Postmortem analysis confirmed the phenotypic discordance. To our knowledge, this is the first reported prenatal diagnosis of MZ male twins with different Down syndrome phenotypes but identical karyotypes. We discuss the mechanisms involved in phenotypic discordance of monozygotic twins and particularly the role of environmental factors.

[Multiple recurrent papillomas of the breast: case report]. / Papillomes multiples récidivants du sein: à propos d'un cas.

We report the case of a patient presenting multiple recurrent papillomas of the breast. This mild mammary pathology, developed at the expense of the galactophoric ducts, recurred four times, in a nodular way, in spite of in sano surgical resection. The retrospective study of the cell proliferation and the DNA quantification of the cells constitutive of the papillomas, on several samples, underlined evolutive lesions, which could be predictive of a malignant degeneration. This observation allows us to discuss the management of this rare mild mammary pathology, which can sometimes lead to invasive breast carcinoma.

[Management of in situ cervical adenocarcinoma]. / Prise en charge de l'adénocarcinome in situ du col utérin.

The management of adenocarcinoma in situ of the cervix (ACIS) is difficult because it is often diagnosed in younger women who may wish to preserve their potential of fertility. Conservative treatment has been accepted as an appropriate strategy but interrogations persist as to carcinological safety. We report a complete review of the literature on this subject where conservative attitude appears possible but is associated with recurrence risk (5 to 10%) and invasive disease (2%). Conditions to perform conservative management are: cold knife cone biopsy, negative margins, cone resection of at least 25 mm, realization of endocervical curettage and total patient compliance. In all cases, regular cytological and histological monitoring must be performed. If maintaining reproductive capacity is not desired, hysterectomy is systematically proposed to patient.

Endometrial tumor invasiveness is related to metalloproteinase 2 and tissue inhibitor of metalloproteinase 2 expressions.

Matrix metalloproteinase (MMPs) expression has been linked to gynecological tumor aggressiveness. The objective of this study was to determine MMP-2, MMP-7, and MMP-9 and tissue inhibitors of metalloproteinases (TIMP)-1 and TIMP-2 expression in endometrial malignancies and their relation to clinical and histologic parameters. Formalin-fixed, paraffin-embedded tumor samples from 50 patients with endometrial carcinoma treated between 1999 and 2004 were stained with specific monoclonal antibodies. The tumors were grouped according to the FIGO classification. The staining results were compared to histologic and clinical data. Semiquantitative analysis of MMP and TIMP expression showed a significant difference in TIMP-2 expression according to the histologic subtype (P = 0.03) and also a trend towards a difference in MMP-9 expression (P = 0.05). MMP-2 expression increased and TIMP-2 expression fell as the histologic grade increased (P = 0.0007, P < 0.0001, respectively). MMP-2 expression correlated with lymph node metastasis (P = 0.04), while TIMP-2 expression correlated with the depth of myometrial invasion (P = 0.01), vasculolymphatic space involvement (P = 0.02), and lymph node metastasis (P = 0.0003). These results support the involvement of MMPs and TIMPs in endometrial tumor growth and progression. High MMP-2 and low TIMP-2 expression were the most potent markers of endometrial tumors with a high risk of local and distant spread.

Continuous combined hormone replacement therapy with 1 mg 17beta-oestradiol and 5 mg dydrogesterone (Femoston-conti): endometrial safety and bleeding profile.

OBJECTIVES: The aim of the study was to confirm the endometrial safety and describe the bleeding profile of continuous combined 1 mg 17beta-oestradiol and 5 mg dydrogesterone in post-menopausal women. METHODS: An open, multicentre study was carried out in 290 healthy, non-hysterectomised post-menopausal women receiving oral continuous combined 1 mg 17beta-oestradiol and 5 mg dydrogesterone (Femoston-conti) for 1 year. Aspiration endometrial biopsies were performed at baseline and at the end of the study; those classified as hyperplasia or malignancy were considered treatment failures. RESULTS: Only one woman developed simple hyperplasia without atypia at the end of the study; the treatment failure rate was therefore 0.4%. Cross-sectional analysis showed that the percentage of women without bleeding increased from 71% during the first cycle to around 80% by the end of the study. Approximately 50% of the bleeding episodes occurred in the form of spotting; severe bleeding was rare and only seven women withdrew prematurely from the study due to uterine bleeding. Overall, 41% of the women were amenorrhoeic throughout the study. CONCLUSIONS: Continuous combined 1 mg 17beta-oestradiol and 5 mg dydrogesterone provides excellent endometrial safety and is associated with an acceptable bleeding profile.

[Update on contraception]. / Mise au point sur la contraception.

Since the introduction of hormonal contraceptives in the 1960s, great advances have been achieved in contraception. Biological effects of sexual steroids as well as risks and benefits of oral contraception are better estimated. After the development of a new hormone-containing intra-uterine system, new hormone delivery systems offer women safe and effective contraceptive options. These new options that combine high efficacy and ease of use should allow better acceptance and compliance than daily pill ingestion and should then reduce the high rate of unintended pregnancies terminated by elective abortion. Transdermal contraceptive system and vaginal ring offer a promising innovative approach in pregnancy prevention. Subdermal implants give women the choice of a highly effective contraceptive system in spite of significant side effects. New hormonal delivery systems such as injectables are under development. Hysteroscopic tubal sterilization is now also available and is a very effective procedure. This wide variety of new contraceptive methods offers a marked improvement from previous medications for users by providing better efficacy and tolerability.

Usefulness of HPV testing in the follow-up of untreated cervical low grade lesions.

The aim of the present work was to evaluate the usefulness of high-risk human papillomavirus (HR-HPV) testing for the follow-up of women with untreated low grade cervical squamous cell lesions (LSIL). For that, 412 women with a cytological diagnosis of LSIL at entry were monitored by cytology, HR-HPV testing with the Hybrid Capture II assay (HC-II) and colposcopy. Our primary endpoint was clinical progression defined by the presence of a high grade cervical intraepithelial neoplasia (CIN2 and CIN3) at the biopsy. At baseline, histological control revealed 10 CIN2 and 11 CIN3 only in the cohort of women HR-HPV+. In the follow-up, 4 CIN2 and 8 CIN3 were detected, always in the women initially HR-HPV+. Thus, the recurrence of a HR-HPV+ infection clearly selects a population at high-risk for CIN2-3. The semi-quantitative appreciation of the viral load with HC-II could not be used as a good prognostic factor for the follow-up of women with LSIL. HR-HPV testing reduces the number of cytology and colposcopy examinations in the follow-up of women aged >35 years when HPV testing is initially negative. Thus HR-HPV testing should be reserved for the follow-up of this population of women initially HR-HPV+ and proposed 6 to 12 months after the cytological diagnosis of LSIL.

Comparison of liquid based cytology and histology for the evaluation of HER-2 status using immunostaining and CISH in breast carcinoma.

BACKGROUND: HER-2 amplification is an important prognostic biomarker and treatment determinant in breast carcinoma. AIMS: To correlate immunocytochemical (ICC) expression of HER-2 and gene amplification determined by chromogenic in situ hybridisation (CISH) using liquid based cytology (LBC) with immunohistochemistry (IHC) and CISH using histological samples of the same breast carcinomas. METHODS: Frozen sections and cytobrushings of 103 breast carcinomas were analysed. Four techniques were performed on each tumour: two on LBC samples (ICC, and CISH, both graded as positive, indeterminate, or negative) and two on histological samples (IHC and CISH). Two cell lines (MCF-7, negative; BT 474, positive) were used as controls for cytological analysis. A complementary fluorescence in situ hybridisation technique was carried out in histological samples with low amplification (4-10 dots/nucleus). RESULTS: Interobserver agreement for the four techniques calculated by the kappa coefficient indicated a substantial agreement. Nine cases failed in cytology because of poor cellularity. Among 94 cases, 19 were amplified; 73, 12, and 9 tumours were scored 0 or 1+, 2+, and 3+, respectively by IHC and 75, 13, and 6, respectively, by ICC. CISH found no amplification in 72 tumours. Correlations between the IHC and CISH results in the histological and cytological samples were always significant. CONCLUSIONS: Her-2 status could be determined in LBC samples and correlated well with reference histological methods using in situ hybridisation. ICC was less reliable because of the presence of the cytoplasmic membrane. However, these results should be confirmed by a large multicentre study.

[Kartagener's syndrome and infertility: observation, diagnosis and treatment]. / Syndrome de Kartagener et stérilité: observation, diagnostic et prise en charge.

Primary ciliary dyskinesia is a rare etiology of sterility in man (prevalence between 1/6000 and 1/40000). Kartagener's syndrome is an autosomal recessive disorder, characterized by total or partial dysfunction of the ciliary or flagellated cells. This syndrome associates situs inversus, sinusitis, bronchiectasis and occasionally sterility in males. We report a case of immotile cilia syndrome with male infertility and compare the data with four other couples reported in the literature (two couples in Germany, two in the United States). The difficulty is to select an alive sperm cell for ICSI.

[Sacrococcygeal teratomas: is there a place for in utero treatment of complicated forms? About three cases]. / Y a-t-il une place pour le traitement in utero des formes compliquées? A propos de trois cas.

The majority of sacrococcygeal teratomas diagnosed before birth can be managed by planned delivery and postnatal surgery. However, large tumors early in gestation may result in placentomegaly, hydrops and fetal death and a preeclampsia-like syndrome in the mother. This is due to high output cardiac failure in the fetus caused by arteriovenous shunting through the tumor. In these cases, in utero treatment may offer improved chances of survival, and emerging technologies should lower fetal and maternal morbidity. Nevertheless, these therapeutics need to be correctly evaluated.

Negative human papillomavirus testing in normal smears selects a population at low risk for developing high-grade cervical lesions.

High-risk human papillomaviruses (HR-HPV) are the necessary cause of cervical carcinomas and there is an increasing interest in using HR-HPV DNA detection in adjunction to cytological examination for primary cervical screening. To determine whether women with a normal smear negative for HR-HPV DNA detection with the Hybrid Capture II assay might represent a low-risk population for developing a high-grade squamous intraepithelial lesion (HSIL), 4401 women have been followed in a period of 12-72 months (median=34 months). During this follow-up, four HSIL and one microinvasive carcinoma have been detected in this cohort (three in the cohort of 3526 women >29 years). The global negative predictive value (NPV) of double-negative tests is thus of 99.9% (ninety-five percent confidence interval (95% CI): 99.8-100%), whereas cytology alone gives an NPV of 99.2% (95% CI: 98.9-99.5%). If we obtain a second negative HR-HPV test 1-2 years after the initial test, the NPV is 100%. The NPV is also of 100% in the cohort of women >49 years. We conclude that all these women could be safely screened at longer intervals between 3 and 5 years. This policy will offset the increased costs induced by an additional HR-HPV testing in primary screening.

[Ultrasonographic measurement of cervical length in twin pregnancies with preterm labor: comparison with singleton pregnancies]. / Mesure échographique de la longueur du col de l'utérus dans les grossesses gémellaires avec menace d'accouchement prématuré: comparaison avec les grossesses uniques.

OBJECTIVE: Our purpose was to assess the utility of ultrasonographic measurement of cervical length for predicting preterm delivery in pregnant women with twin pregnancy and preterm labor. PATIENTS AND METHOD: Prospective study in 192 singleton and 66 twin pregnancies with preterm labor before 34 weeks. Vaginal sonography for measurement of cervical length, and screening for fetal fibronectin in vaginal smears were performed at admission. The incidence of delivery before 34 weeks was compared with cervical length and the presence of fetal fibronectin. RESULTS: In singleton pregnancies, delivery before 34 weeks was significantly more frequent in women with a cervical length <30 mm (26.6 vs. 2.0%; P = 0.0004), or presence of fetal fibronectin (27.5 vs. 6.0%; P = 0.001). The corresponding negative predictive values (NPV) were 98% and 94%, respectively. In twin pregnancies, receiver characteristic curve analysis showed that a cervical length of 20 mm had the highest diagnostic performance in predicting preterm delivery. The corresponding NPV was 63%. In this group, delivery before 34 weeks showed no significant difference in women with a cervical length < 30 mm (43.7 vs. 38.8%), cervical length < 20 mm (52.0 vs. 36.6%, P = 0.219), or presence of fetal fibronectin (47.6 vs. 21.7%, P = 0.0705). DISCUSSION AND CONCLUSION: Ultrasonographic measurement of cervical length does not predict preterm delivery in twin pregnancies with preterm labor.

[Isolated torsion of the Fallopian tube in a 15-year old adolescent. About one case]. / Torsion tubaire isolée chez une adolescente de 15 ans. A propos d'un cas.

Isolated torsion of the Fallopian tube is an uncommon event. Surgery is often necessary to establish the diagnosis. This report focuses on a 15-year old female who presented with acute pelvic pain. Pelvic ultrasound showed an adnexal mass. The laparoscopy performed confirmed the diagnosis of isolated tubal torsion. Based on this experience as well as on other similar reported cases, characteristics of isolated torsion of the Fallopian tube are discussed. This pathology should be considered in the differential diagnosis of acute pelvic pain in the female patient. Prompt surgical intervention may allow for preservation of the tube.