Accuracy of combinations of visual inspection using acetic acid or lugol iodine to detect cervical precancer: a meta-analysis.

BACKGROUND: Visual inspection of the cervix with acetic acid (VIA) or with Lugol's iodine (VILI) have been evaluated for cervical cancer screening in developing countries. OBJECTIVES: To assess the diagnostic accuracy and clinical utility of visual methods to detect cervical intraepithelial neoplasia grade 2+ (CIN2+) using: (1) VIA alone; (2) VILI alone; (3) co-testing; and (4) VILI as a triage test of a positive VIA result. SEARCH STRATEGY: PubMed, EMBASE, and the Cochrane Library were searched up to May 2016. SELECTION CRITERIA: All reports on the accuracy of VIA and VILI, or combinations of VIA/VILI, to detect CIN2+ were identified. Histology and colposcopy when no biopsy was taken were used as the reference standard. DATA COLLECTION AND ANALYSIS: Selected studies were scored on methodological quality, and sensitivity and specificity were computed. Clinical utility was assessed from the positive predictive value (PPV) and the complement of the negative predictive value (cNPV). MAIN RESULTS: We included 23 studies comprising 101 273 women. The pooled sensitivity and specificity of VILI was 88 and 86%, respectively. VILI was more sensitive, but not less specific, compared with VIA (relative sensitivity = 1.11; 95% confidence interval, 95% CI, 1.06-1.16; relative specificity = 0.98; 95% CI 0.95-1.01). Co-testing was hardly more sensitive, but significantly less specific, than VILI alone. VILI to triage VIA-POSITIVE women was not less sensitive, but more specific, compared with VIA alone (relative sensitivity = 0.98, 95% CI 0.96-1.01; relative specificity = 1.04, 95% CI 1.02-1.05). The average PPVs were low (range 11-16%), whereas the cNPV varied between 0.3% (VILI, co-testing) and 0.6% (triage). CONCLUSIONS: Although imperfect, VILI alone appeared to be the most useful visual screening strategy. TWEETABLE ABSTRACT: VILI alone seems to be the most useful visual screening test for cervical cancer screening.

Endometriosis after menopause: physiopathology and management of an uncommon condition.

Endometriosis is a hormone-dependent inflammatory disease that is usually characterized by infertility and pain symptoms. This disease mainly occurs during the reproductive years and is rarely diagnosed after menopause. We discuss the physiopathology of this condition after menopause as well as treatment options and the risk of malignant transformation. Occurrence or progression of postmenopausal endometriosis lesions could be related to extra-ovarian production of estrogen by endometriosis lesions and adipose tissue, which becomes the major estrogen-producing tissue after menopause. Postmenopausal women with symptomatic endometriosis should be managed surgically because of the risk of malignancy; medical treatments can be used in cases of pain recurrence after surgery. Aromatase inhibitors act by decreasing extra-ovarian estrogen production and by blocking the feed-forward stimulation loop between inflammation and aromatase within endometriosis lesions. The evidence is currently insufficient to support a conclusion about the optimal hormone replacement therapy for women with endometriosis. The question of malignant transformation of endometriosis in response to hormone replacement therapy in women with a history of endometriosis remains unanswered and needs a long-term follow-up study to evaluate the risk of an adverse outcome. Further studies should be performed to determine the optimal management of menopausal women with endometriosis.

Stage IVB endometrial cancer: clinical course and survival of patients with single and multiple metastases.

OBJECTIVE: Metastatic endometrial cancer (EC) at initial presentation is a rare disease. The present aim was to evaluate prognostic factors and overall survival in patients diagnosed with metastatic EC. STUDY DESIGN: Using data from the Geneva Cancer Registry, the authors included all patients diagnosed with Stage IVB EC from 1980-2007. Estimates of survival were calculated using the Kaplan-Meier method and compared using the log-rank test. RESULTS: A total of 38 patients were identified. The most frequent metastases were peritoneal or pleural carcinomatosis (66%, n=25) and hematogenous metastases (53%, n=20). Five-year survival rate was 5.7% (95% confidence interval: 0.0-13.3), and median survival was 7.6 months. Survival of patients with a single metastasis at the time of diagnosis was longer than for patients with multiple metastases (16 versus two months, respectively; p < 0.00 1). CONCLUSION: Metastatic EC is rare disease with very poor prognosis particularly for patients with multiple site metastases.

Advances in neurosteroids: role in clinical practice.

The steroidogenic endocrine glands and local synthesis both contribute to the pool of steroids present in the central nervous system and peripheral nervous system. Although the synthesis of neurosteroids in the nervous system is now well established, the spectrum of respective functions in regulating neuronal and glial functions remains to be fully elucidated. From the concept of neurosteroids derives another treatment strategy: the use of pharmaceutical agents that increase the synthesis of endogenous neurosteroids within the nervous system. This approach has so far been hampered by lack of knowledge concerning the regulation of the biosynthetic pathways of neurosteroids and their relationship with sex steroids produced by the peripheral gland or with exogenous steroids. The present review summarizes some of the available clinical and experimental findings supporting the critical role of neurosteroids during fertile life and reproductive aging and their relationship with endogenous and exogenous sex steroids. The brain metabolism of synthetic progestins and the implications of DHEA treatment in postmenopausal women will also be discussed.

Overexpression of GRP78 in complete hydatidiform moles.

OBJECTIVE: Hydatidiform moles, subdivided into partial moles (PM) and complete moles (CM), are abnormal pregnancies with a disturbed invasive behavior. We had previously shown that MMP-2 and p53 proteins are overexpressed in CM versus PM, and that in primary cytotrophoblasts p53 protein is stabilized by complexing to the 78kDa glucose-regulated protein (GRP78) which is involved in cytotrophoblasts invasion process. The present study aims to compare the transcript expression profile of p53, MMP-2 and GRP78 in hydatidiform moles. METHODS: A retrospective study was performed by RT-qPCR and immunostaining on paraffin-embedded tissues of 19 PM, 16 CM and 16 control (CTRL) samples of gestational age 8-12 weeks. RESULTS: Expression of MMP-2 transcript was significantly overexpressed in CM compared to CTRL samples (p=0.031). In contrast, expression of p53 transcript was similar among the samples. This suggests a regulation of p53 in CM at the protein level. GRP78 cDNA was significantly overexpressed in CM compared to CTRL (p=0.021) and to PM (p=0.011). At the protein level, immunostaining of GRP78 was on average stronger in CM than PM samples. CONCLUSIONS: Collectively, present data suggest that in CM, p53 is normally expressed at the mRNA level but probably complexes at the protein level with the overexpressed GRP78, leading to accumulation of p53 protein. Moreover, since GRP78 and MMP-2 are increased in CM and known to play key roles in invasion, our results suggest that GRP78 and MMP-2 should be investigated as prognostic markers of hydatidiform moles.

[What's new in gynecology and obstetrics]. / Gynécotogie et obstétrique.

Because of the lack of screening methods, ovarian cancer remains one of the major causes of mortality in gynecological oncology. Prevention by salpingectomy, based on a concept about the origin of serous carcinoma, may be proven effective in the future. Regarding cervical cancer, screening methods are improving and the benefit of HPV-HR testing has been recently demonstrated. Metabolic requirements and exercise are modified during pregnancy. Present recommendations are for pregnant women to practice regular moderate exercise, as in a non-pregnant population. This guideline, despite being reasonable, is not based on strong evidence. A randomised trial is ongoing in our Department to evaluate the effects of exercise in women with gestational diabetes.

[Trophoblastic diseases: a multidisciplinary approach, a first Swiss center]. / Maladies trophobtastiques: une prise en charge pluridisciplinaire, un premier centre suisse.

Trophoblastic diseases are rare and complex. The Center for trophoblastic diseases, the first in Switzerland, was founded in Geneva in January 2009 to formalize the collaboration between obstetricians-gynecologists, pathologists, geneticists, radiologists and oncologists. At the physician's request and with patient consent, an integrative diagnosis is proposed after centralized review of the histological slides, anti-p57KIP2 immunohistochemistry, and ploidy analysis by QF-PCR (Quantitative fluorescent polymerase chain reaction). The referring physician receives treatment and beta-hCG dosage recommendations. This pluridisciplinary diagnostic and therapeutic approach allows optimal surveillance and treatment of patients.

[Gynecology]. / Gynécologie.

Widespread use of the Pap test for cervical cancer screening has dramatically reduced cervical cancer incidence and mortality rates. The knowledge about optimal use of cervical cancer screening has evolved these last year and conducted to improve new cervical prevention. The American College of Obstetricians and Gynecologists (ACOG) recommend that cervical cancer screening should not begin before the age 21 years and that screening tests should be performed at less frequent intervals. CA 125 is considered to be the best test to detect relapse among women previously treated for ovarian cancer. However, a recent randomized trial has reported that there is no benefice to initiate the therapy before presence of symptoms. In 2009, the FIGO published a revised staging for cervical, endometrial and vulvar cancer to improve prognostic disease and therapy decision.

[Septic arthritis]. / Arthrite septique.

Septic or acute bacterial arthritis is a medical emergency. The primary physician must suspect this condition even when clinical symptoms are non specific or with simultaneous inflammatory arthropathy. Septic arthritis can have serious complications. Optimal care requires hospital admission in general. Synovial fluid aspiration and its correct interpretation, the appropriate choice and timely administration of empiric antibiotic therapy can limit destruction of the joint's cartilage. The adaptation of the antibiotic regimen after reception of microbiological results and the adequate treatment in full length require interdisciplinary collaboration between the hospital physician, including the specialist in infectious diseases, the microbiology laboratory and post-hospital care.

[Diagnostic of Pneumocystis jirovecii pneumonia in a non HIV patient]. / Diagnostic de la pneumonie à Pneumocystis jirovecii chez le patient non VIH.

Pneumocystis jirovecii pneumonia is an opportunistic infection affecting not only HIV patient but also patients with others causes of immunosuppression. The reference method for the diagnostic is the direct visualization of the pathogen in induced sputum or in bronchoalveolar lavage with a low sensibility. Direct immunofluorescence does not increase significantly this sensibility on IS. The PCR has been demonstrated to have 100% sensitivity. This gives rise to the problem of falsely positive results in patients, colonized by P. jiroveci (8,9-26,9%) but suffering from a pneumonia due to another pathogen. Use of quantitative PCR or serum beta-D-glucan, might be helpful to distinguish colonization from infection. This paper reviews the literature on the diagnostic of PCP in non HIV patients.

[LESS, NOTES and robotic surgery in gynecology: an update and upcoming perspectives]. / Chirurgie LESS, NOTES et robotique en gynécologie: mise au point et perspectives.

Laparoscopy revolutionized the gynecological surgical world during the 1980's and 1990's and has changed the approach to surgical procedures ever since. Minimal invasive surgery procedures are now the standard of care for many gynecological operations. At the beginning of the 21st century, robotic gynecological surgery, laparo-endoscopic single site surgery (LESS) and natural orifice transluminal endoscopic surgery (NOTES) may be on the threshold of another such revolutionary breakthrough. In this article, we review the present place of these new techniques in gynecological surgery and discuss their future perspective.

[Ovarian cancer screening: recommendations for clinical pratice]. / Dépistage du cancer de l'ovaire: recommandations pour la pratique clinique.

Ovarian cancer accounts for a minority of female cancers but remains the leading cause of death from gynaecologic cancers and the fifth leading cause of all cancer-related deaths among women. More than two thirds of cases of ovarian cancer are diagnosed once the disease becomes symptomatic, i.e. at an advanced stage. Though early detection constitutes a legitimate aim, no screening approach has yet been shown to reduce ovarian cancer mortality. In particular, ovarian imagery with endovaginal ultrasonography and serum tumor markers (CA-125) dosage performed in asymptomatic individuals have not proven their efficacy. Screening of asymptomatic women is not therefore recommended because of the limited prevalence of ovarian cancer in the general population.

Effectiveness of vaginal hysterectomy for benign conditions in semi-urban hospital: report from Maroua-Cameroon.

We assessed the effectiveness of vaginal hysterectomy for benign uterine conditions in Northern Cameroon. This is a case series study of 29 elective vaginal hysterectomies carried out between February 2005 and June 2007 in Maroua, Cameroon. Hysterocele was found as the only or associated indication in 17 (58.6%) patients, symptomatic uterine fibroids in 4 (13.8%) and other indications in 8 (27.6%) patients. The mean duration of the operation was 132 minutes and the mean blood loss at surgery was 150 ml. Twenty-five of the 28 (89.3%) women had less than seven days of hospitalisation. There was a negative correlation (r = -0.45, P = 0.015) between duration of the surgery and the order of operation. One urinary tract and one wound infection were observed. Two patients had conversion to laparotomy. This study has shown that vaginal hysterectomy is a safe and feasible method of hysterectomy in a semi-urban hospital.

The attitude and knowledge of cervical cancer by Cameroonian women; a clinical survey conducted in Maroua, the capital of Far North Province of Cameroon.

This study was conducted to assess the knowledge, attitudes, and assumption of cervical cancer by women living in Maroua, the capital of the Far North Province of Cameroon. In a 1-month period, 171 women were surveyed as to their socioeconomic status, sexual habits, prior knowledge of cervical cancer, its prevention, and their attitudes toward cervical cancer. Of 171 women, 48 (28%) had prior knowledge of cervical cancer; they were classified as the "aware group" compared with 123 of 171 (72%) women who were uninformed about cervical cancer and they were classified as the "unaware group" (UG). The UG of women tended to be single mothers, illiterate, housewives, and had their first child before the age of 20 (P < 0.005). Despite the awareness of cervical cancer by 28% of women, only a minority of them, 4 of 48 (8.3%), underwent a preventative screening test. Only 71 of 171 (41.5%) women stated that they would be having a screening test in the future. The awareness of cervical cancer by women in Cameroon is still inadequate. Thus, to avoid deaths from cervical cancer, a curable and preventable disease, the need of an aggressive campaign to make Cameroonian women aware of cervical cancer and its prevention is needed.

Outcome of uterine clear cell carcinomas compared to endometrioid carcinomas and poorly-differentiated endometrioid carcinomas.

OBJECTIVES: Our aim was to compare the survival between patients with clear cell carcinoma (CC) and patients with endometrioid carcinoma (EC). METHODS: Through the population-based Geneva Cancer Registry, we identified 1,380 resident women diagnosed with uterine cancer between 1970 and 2000. We excluded those with papillary serous endometrial carcinoma and uterine sarcomas. We categorized patients as CC (n = 32, 2.8%) or EC (n = 1,145, 97.2%). Uterine cancer-specific survival rates were calculated by Kaplan-Meier analysis. We used Cox proportional hazards analysis to compare uterine cancer mortality risks between groups, and adjusted these risks for other prognostic factors. RESULTS: CC patients presented with a more advanced stage at diagnosis than EC patients (p = 0.002). Compared to women with EC, women with CC had a significantly greater risk of dying from their disease (hazard ratio [HR] 2.9, 95% confidence interval (95% CI) 1.7-4.9). After adjustment for age, stage and adjuvant chemotherapy, the risk of dying from uterine cancer was still significantly higher for CC patients (HR 2.0, 95% CI 1.2-3.4). By univariate analysis, the risk of dying of endometrial cancer was not significantly higher in CC patients than in patients with poorly-differentiated EC (HR 1.3, 95% CI 0.7-2.3). CONCLUSION: This population-based investigation shows that patients with CC have a poorer outcome than those with EC. Studies to determine the role of adjuvant treatment in CC patients are needed.

[What's new in gynecology and obstetrics?]. / Gynécologie.

Among the improvements in gynecology reported in 2007, we highlight those in the field of cervical cancer. A randomized trial showed that HPV testing has higher sensitivity compared to the screening based on Papanicolaou smears. The recent availability of a HPV vaccine is also an important event. In obstetrics, the results of several trials evaluating the administration of progesterone to prevent preterm birth were published. The benefit of the administration of progesterone is still controversial. Prevention of early onset groupe B Streptococcus sepsis might be improved by rapid PCR testing during labor.

[Laparoscopy in the management of endometrial cancer]. / Place de la laparoscopie dans le traitement du cancer de l'endomètre.

Recent advance in laparoscopy have changed the surgical approach of endometrial cancer patients. The Swissendos Center, Fribourg, in collaboration with AGO (Groupe de travail pour la gynécologie oncologique) and AGE (groupe de travail pour la gynécologie endoscopique) have established a consensus based on the available evidence for the use of laparoscopy in the management of patients with endometrial cancer The main objective was to define Swiss clinical practice guidelines appropriate to the country and consistent with the needs of the physicians.

[Proper usage of procalcitonin]. / Du bon usage de la procalcitonine.

In the last fifteen years, procalcitonin measurement has been evaluated as a rapid diagnostic aid for suspected infection. Procalcitonin is now widely used in any febrile patient despite the lack of evidence supporting that practice. Indeed, procalcitonine has proven effective in the intensive care setting, as a diagnostic aid for septic shock, as a prognostic instrument and to tailor the duration of antibiotic treatment. Studies in non intensive care settings are more recent and scarce. Procalcitonin has been assessed in the emergency department in patients with lower respiratory tract infections and in patients admitted for an acute febrile illness. Results are encouraging but preliminary, therefore procalcitonine measurement should be restricted to patients with criteria of severe infection for the time being.

[What's new in gynecology in 2006?]. / Gynécologie.

There were two good news in gynecologic oncology in 2006: intraperitoneal (IP) chemotherapy and the prophylactic vaccines for human papilloma virus (HPV). The ovarian cancer is usually limited to the peritoneal cavity and IP chemotherapy is associated with increased local concentrations. A benefit of this approach on survival was shown in three randomized trials and justifies the recommendation of this treatment for women with a Stage III ovarian cancer, after optimal surgery. Randomized trials have demonstrated the efficacy of two HPV vaccines to prevent a new infection and cytological abnormalities of the cervix. These vaccines will soon be available in Switzerland.

Adjuvant therapy for patients with stage I papillary serous endometrial cancer.

Uterine papillary serous carcinoma (UPSC) is an aggressive variant of endometrial cancer characterized by a high recurrence rate and poor prognosis. Several studies have demonstrated that UPSC has a tendency to manifest with extra-uterine disease, even for tumors which appear to be limited to the endometrium. The data on adjuvant chemotherapy for stage I UPSC are limited, and the available studies are generally under-powered to assess if chemotherapy improves survival. However, we believe that, patients with UPSC should receive complete surgical staging, including omentectomy and peritoneal biopsies, and then until the results of larger series or randomized controlled trials will be available, we feel that combined radiotherapy and chemotherapy is justified for all stage I UPSC.