[Surgery or not on an atypical breast lesion? Taking anxiety into account in shared decision support from a prospective cohort of 300 patients]. / Opérer ou non une lésion atypique du sein ? Prise en compte de l'anxiété dans l'aide à la décision partagée à partir d'une cohorte prospective de 300 patientes.

INTRODUCTION: Organized and individual breast screening have been accompanied by an increase in the detection of "atypical breast lesions (ABL)". Recently, the NOMAT multicenter study proposed a predictive model of the risk of developing breast cancer after detection of an ABL in order to avoid surgical removal of "low-risk" lesions. It also aimed to provide information on psychological experience, in particularly anxiety, to assist in the shared medical decision process. METHODS: Three hundred women undergoing surgery for ABL were included between 2015 and 2018 at 18 French centers. Women completed questionnaires before and after surgery assessing their level of anxiety (STAI-State, STAI-Trait), their level of tolerance to uncertainty, their perceived risk of developing a breast cancer, and their satisfaction with the management care. RESULTS: One hundred nighty nine patients completed the STAI-Status before and after surgery. Overall, a decrease in anxiety level (35.4 vs 42.7, P<0.001) was observed. Anxious temperament and greater intolerance to uncertainty were significantly associated swith decreased anxiety (33%), whereas younger age was associated with increased anxiety (8%). CONCLUSION: Surgery for ABL seems to be associated with only a few cases with an increase in anxiety and seems to increase the perception of the risk of developing breast cancer. Taking into account the psychological dimension remains in all cases essential in the process of shared therapeutic decision.

Comparison of breast density assessment between human eye and automated software on digital and synthetic mammography: Impact on breast cancer risk.

PURPOSE: To evaluate the agreement between automatic assessment software of breast density based on artificial intelligence (AI) and visual assessment by a senior and a junior radiologist, as well as the impact on the assessment of breast cancer risk (BCR) at 5 years. MATERIALS AND METHODS: We retrospectively included 311 consecutive women (mean age, 55.6±8.5 [SD]; range: 40-74 years) without a personal history of breast cancer who underwent routine mammography between January 1, 2019 and February 28, 2019. Mammographic breast density (MBD) was independently evaluated by a junior and a senior reader on digital mammography (DM) and synthetic mammography (SM) using BI-RADS (5th edition) and by an AI software. For each MBD, BCR at 5 years was estimated per woman by the AI software. Interobserver agreement for MBD between the two readers and the AI software were evaluated by quadratic κ coefficients. Reproducibility of BCR was assessed by intraclass correlation coefficient (ICC). RESULTS: Agreement for MBD assessment on DM and SM was almost perfect between senior and junior radiologists (κ=0.88 [95% CI: 0.84-0.92] and κ=0.86 [95% CI: 0.82-0.90], respectively) and substantial between the senior radiologist and AI (κ=0.79; 95% CI: 0.73-0.84). There was substantial agreement between DM and SM for the senior radiologist (κ=0.79; 95% CI: 0.74-0.84). BCR evaluation at 5 years was highly reproducible between the two radiologists on DM and SM (ICC=0.98 [95% CI: 0.97-0.98] for both), between BCR evaluation based on DM and SM evaluated by the senior (ICC=0.96; 95% CI: 0.95-0.97) or junior radiologist (ICC=0.97; 95% CI: 0.96-0.98) and between the senior radiologist and AI (ICC=0.96; 95% CI: 0.95-0.97). CONCLUSION: This preliminary study demonstrates a very good agreement for BCR evaluation based on the evaluation of MBD by a senior radiologist, junior radiologist and AI software.

Prospective, randomized comparison of the use of FloShield Air System® versus the reference technique (water + povidone-iodine solution) during gynecologic endoscopic surgery to evaluate the operative lens vision quality.

BACKGROUND: The FloShield Air System® is a new device for laparoscopic surgery that utilizes a continuous dry CO2 gas flow over the scope to defog the lens and protect it from condensation, debris and smoke. We set out to compare the performance and efficiency of the device in terms of operative lens vision quality (OLVQ) with the reference technique (water + povidone-iodine (PVI) solution) during gynecologic laparoscopic surgery. MATERIALS AND METHODS: We conducted a single-center randomized prospective study between March and June 2016 (Trials Database Registration NCT02702531) including 53 patients undergoing gynecologic laparoscopic surgery with water + PVI solution and 51 patients who underwent surgical procedures with the FloShield Air System. The primary outcome measure was the number of laparoscope removals during surgery. Secondary outcome measures were the time to clean, assessment of the quality of vision, the correlation between the laparoscopic surgical complexity and outcomes, and cost effectiveness. RESULTS: Overall, the mean patient age was 43.2 years (range 22-86) and body mass index 24.8 (range 16.8-42.7). The mean number of endoscope removals during surgery was 7.0 (range 0-37) in the water + PVI solution arm and 2.8 (range 0-12) in the FloShield Air System® arm. The number of removals was significantly lower in the FloShield arm (p < 0.001). No difference in time to clean, quality of vision, level of laparoscopic procedure complexity, or cost was observed between the groups. CONSLUSIONS: The FloShield Air System® resulted in fewer laparoscopic lens removals than the water + PVI solution solution, but that there was no difference in quality of vision, cleaning time or cost, especially for the more complex surgery.

Fertility before and after surgery for deep infiltrating endometriosis with and without bowel involvement: a literature review.

AIM: Endometriosis affects from 10% to 15% of women of childbearing age and 20% of these women have deep infiltrating endometriosis (DIE). The goal of this review was to assess the impact of various locations of DIE on spontaneous fertility and the benefit of surgery and Medically Assisted Reproduction (MAR) (in vitro fertilization and intrauterine insemination) on fertility outcomes. METHODS: MEDLINE search for articles on fertility in women with DIE published between 1990 and April 2013 using the following terms: "deep infiltrative endometriosis", "colorectal", "bowel", "rectovaginal", "uterosacral", "vaginal", "bladder" and "fertility" or "infertility". Twenty-nine articles reporting fertility outcomes in 2730 women with DIE were analysed. RESULTS: Among the women with DIE and no bowel involvement (N.=1295), no preoperative data on spontaneous pregnancy rate (PR) were available. The postoperative spontaneous PR rate in these women was 50.5% (95% Confidence Interval [CI] =46.8-54.1) and overall PR (spontaneous pregnancies and after MAR) was 68.3% (95% CI=64.9-71.7). No evaluation of fertility outcome according to locations of DIE was feasible. For women with DIE with bowel involvement without surgical management (N.=115), PR after MAR was 29%; 95% CI=20.7-37.4). For those with bowel involvement who were surgically managed (N.=1320), postoperative spontaneous PR was 28.6% (95% CI=25-32.3) and overall postoperative PR was 46.9% (95% CI=42.9-50.9). CONCLUSION: For women with DIE without bowel involvement, surgery alone offers a high spontaneous PR. For those with bowel involvement, the low spontaneous and relatively high overall PR suggests the potential benefit of combining surgery and MAR.

Incidence of pre- and postoperative urinary dysfunction associated with deep infiltrating endometriosis: relevance of urodynamic tests and therapeutic implications.

Although many series have been published on the management of digestive or urinary deep infiltrating endometriosis (DIE), few data exist on pre- and postoperative urinary dysfunction (UD) and urodynamic tests. Hence, the objective of this review was to evaluate the pre- and postoperative incidence of UD and the contribution of urodynamic tests as well as their therapeutic implications. Studies published between January 1995 and April 2012, available in the databases Medline, Embase or the Cochrane Library and responding to a key word algorithm were selected. Studies were classified according to their level of evidence in the Canadian Task Force classification. Sixty-three studies were included in this review. The incidence of preoperative UD is unknown in patients with DIE without colorectal involvement but ranges from 2% to 48% in patients with colorectal endometriosis. About half of all the patients had abnormal urodynamic test results. DIE surgery is associated with a risk of urinary dysfunction mainly corresponding to de novo voiding dysfunction in 1.4% to 29.2% of cases with a mean value of 4.8%. The rate of persistent voiding dysfunction ranges from 0 to 14.7% with a mean value of 4.6%. Risk factors of postoperative UD are the need for partial colpectomy, parametrectomy and patients requiring colo-anal anastomosis. For patients with urinary tract endometriosis, the incidence of preoperative UD is comprised between 24.4% and 79.2% with a rate of postoperative voiding dysfunction ranging from 0% to 16.9% with a mean value of 11.1%. Prevention of postoperative UD is based on nerve-sparing surgery. Treatment of voiding dysfunction requires self-catheterization. There is a lack of data on medical treatment and surgical techniques to manage postoperative UD. More effort needs to be made to detect preoperative UD associated with DIE. Preoperative evaluation by urodynamic tests and possibly electrophysiology could be of interest especially in patients with risk factors. The current review underlines the difficulties of establishing clear recommendations due to heterogeneity of the studies and the absence of a consensual definition of UD.

Genital prolapse repair with Avaulta Plus mesh: functional results and quality of life.

PURPOSE: Evaluate anatomic and functional outcomes of genital prolapse repair by vaginal route using a mixed polypropylene and porcine skin mesh. PATIENTS AND METHODS: Prospective pilot study from January 2009 to January 2011 in the gynecologic department of a tertiary university hospital. Twenty patients with stage II-III genital prolapse underwent anterior wall prolapse repair with anterior Avaulta Plus mesh. Functional results were evaluated using the pelvic floor distress inventory-short form (PFDI-20), the pelvic floor impact questionnaire-7 (PFIQ-7) and the Pelvic Organ Prolapse/Urinary Incontinence Sexual questionnaires (PISQ-12). RESULTS: No per-operative complications occurred. One postoperative hematoma (5%) occurred requiring a second surgery. At a mean follow-up of 19.7 months, three patients had vaginal mesh exposure (15%) requiring a second surgery for two of them. Of the 20 women, 17 (85%) had optimal anatomic results and three (15%) had residual genital prolapse (Ba=-2 in two cases and Bp = -2 in the one). No recurrence was observed during the study period. A significant improvement in the PFDI-20 (P<0.001) and PFIQ-7 scores (P<0.001) was observed but no improvement in the PISQ-12 score. CONCLUSION: In this series, we reported that genital prolapse repair using Avaulta Plus mesh resulted in a high success rate and improved quality of life but with an important prevalence of vaginal mesh exposure.

Urological morbidity of colorectal resection for endometriosis.

Colorectal resection for endometriosis is a major operation exposing patients to the risk of severe digestive and urological complications. The objective of this review is to evaluate surgery-related urological morbidity of which little is known to date. We searched MEDLINE for articles published on colorectal resection for endometriosis between 1998 and March 2011 using the following terms: "bowel", "rectal", "colorectal", "rectovaginal", "rectosigmoid", "resection" and "endometriosis". We were not able to perform a meta- analysis due to a lack of complete data on urological complications so have focused this review on voiding dysfunction and ureteral injury. Thirty-two articles reporting on 3047 colorectal resections for endometriosis including 1930 segmental resections, 271 discoid resections and 846 rectal shavings were analysed. For voiding dysfunction, 28 series including 2563 colorectal resections were available. Postoperative voiding dysfunction varied from 0% to 30.4% with a mean value of 3.4% (73/2118). Fourteen series reported an incidence of ureterolysis comprising between 8.5% and 100% with a mean value of 46% (815/1772 patients). The risk of urinary fistulae evaluated in 26 series was estimated at 0.9% (24/2581 patients). Only one case of hydronephrosis was reported in 9 series including 1256 patients (0.07%). The incidence of urological morbidity associated with colorectal endometriosis is poorly documented and probably underestimated due to the short follow-up reported in the series. Moreover, as complication rates varied widely according to the type of surgery and the experience of the teams, further studies are required to identify risk factors of urological morbidity so as to adequately inform patients.

Intrapericardial teratoma with hydrops leading to in utero demise.

We report a case of intrapericardial teratoma following in utero demise at 29 weeks with nonimmune hydrops. The diagnosis was strongly suggested by ultrasound findings and confirmed by fetopathology. The mechanism whereby intrapericardial teratomas may lead to hydrops and death is massive pericardial effusion responsible for compressive tamponade. When prenatal diagnosis is performed before this stage, in utero interventions can obtain decompression, and the birth can be planned with rapid and appropriate management of the neonate.

Acromegaly due to ectopic growth hormone-releasing hormone secretion by a bronchial carcinoid tumour. Dynamic hormonal responses to various stimuli.

Ectopic GHRH is a relatively uncommon cause of acromegaly, which should be differentiated from pituitary adenoma, in order to avoid damage to the pituitary gland from unnecessary interventions. We report here on a 66-year-old man with acromegaly due to a GHRH-secreting bronchial carcinoid tumour, who recovered completely following removal of the tumour. His hormonal status was studied before and after the operation. Basal GH, GHRH, IGF-I and PRL levels, as well as plasma GH response to glucose load and TRH administration were abnormal before the operation, and became normal thereafter. The somatostatin analogue SMS 201-995 was found to be a potent inhibitor of the ectopic GHRH and the GH secretion (greater than 500 to 42 ng/l and 15.4 micrograms/l to 0.8 microgram/l, respectively). The effect on GHRH proved to be due to direct effect of somatostatin on the tumour cells, as demonstrated in tissue culture studies. A mixed meal was found immediately to suppress GHRH levels without such an effect on GH secretion. We conclude that the neuroendocrine tests usually practised in acromegaly cannot differentiate between ectopic GHRH secretion and pituitary adenoma. High plasma GHRH levels may serve as a diagnostic test for excessive GHRH production, which is almost always ectopic. These high levels are suppressible by somatostatin and a mixed meal.

Pericardial meshing: a new technique to facilitate primary tension-free pericardial closure.

A method is described to facilitate pericardial approximation at the conclusion of open-heart surgical procedures. Before sternal closure, the anterior pericardium is meshed by multiple longitudinal incisions until tension-free closure is possible. The technique was developed by animal experimentation and is now being performed in patients. It has proven to be simple, safe, and effective.