How to improve the preoperative staging of presumed early-stage endometrioid endometrial cancer?

PURPOSE OF INVESTIGATION: Accurate preoperative staging of early-stage endometrioid endometrial cancer (EEC) is necessary to avoid under or over surgical treatment. The objective is to determine the rate of understaging and to evaluate the accuracy of different methods: hysteroscopy-curettage versus endometrial biopsy in predicting the final stage. MATERIALS AND METHODS: This retrospective single-centre study led from 2000 to 2010, included women with EEC preoperatively assessed at low- or intermediate-risk. Understaging was defined as a postoperative FIGO Stage > 1 or a determination of high risk after the final histopathologic diagnosis. RESULTS: The study included 101 women (75 low-risk and 26 intermediate-risk). Final diagnosis was upstaged for 26 of them, more frequently in the presumed intermediate-risk group (57.7% vs 14.7%, p < 0.001). The rate of preoperative understaging was higher in the women with endometrial biopsies than those with curettage (34.5% vs 15.2%, p = 0.04). CONCLUSIONS: Hysteroscopy-curettage combined with magnetic resonance imaging (MRI) may improve preoperative staging of early-stage EEC, especially for presumed intermediate-risk disease.

[Mature and immature ovarian teratomas: US, CT and MR imaging features]. / Tératomes ovariens matures et immatures: caractéristiques en échographie, TDM et IRM.

Mature cystic ovarian teratomas, also called dermoid cysts, are one of the most frequent ovarian tumors of younger female patients and are suggested when a fat-containing cystic tumor is identified on imaging. However, the presence of fat is not pathognomonic for dermoid cyst, and it may also be identified in immature teratomas, whose prognosis and treatment are different. Some imaging features are helpful to differentiate between both tumors, including th epresence of enhancement on CT and MRI. Knowledge of the imaging features of these tumors allows for a confident diagnosis to be made in most cases. A few rare and less typical imaging features should also be recognized.

[Robotic assistance in gynaecological surgery: State-of-the-art]. / Assistance robotisée en chirurgie gynécologique : état des lieux.

From the Automated Endoscopic System for Optimal Positioning (AESOP), a robotic arm which operates the laparoscope, to the robots Zeus and da Vinci, robotic assistance in gynaecological endoscopic surgery has continuously evolved for the last fifteen years or so. It has brought about new technical advancements: the last generation robots offer a steady three-dimensional image, improved instrument dexterity and precision, higher ergonomics and comfort for the surgeon. The da Vinci robotic system has been used without evincing any specific morbidity in various cases, notably for tubal reanastomosis, myomectomy, hysterectomy, pelvic and para-aortic lymphadenectomy or sacrocolpopexy amongst others. Robotic assistance in gynaecology is thus feasible. Like conventional laparoscopic surgery, it allows decreased blood loss and morbidity as well as shorter hospital stay, as compared to laparotomy. It might indeed allow many surgical teams to perform minimally invasive surgical procedures which they were not used to performing by laparoscopy. Randomized prospective studies are needed to define its indications more precisely. Besides, its medico-financial impact should be evaluated too.

[Breast cancer and pregnancy]. / Cancer du sein et grossesse.

UNLABELLED: As maternal age at the time of pregnancy continues to increase and the incidence of breast cancer is raising, the incidence of pregnancy associated with breast cancer can be expected to increase. A review of the literature was performed to help identify optimal treatment strategies. METHODS: a search of electronic databases between 1967 and the present identifies studies reporting breast cancer associated with pregnancy. There is a paucity of prospective studies regarding diagnosis and treatment of breast cancer during pregnancy. Women diagnosed with breast cancer during pregnancy have similar disease characteristics to age-matched controls. Current evidence suggests that diagnosis may be carried out with limitations regarding staging. Surgical treatment may be performed as for the non-pregnant women. Radiotherapy and endocrine or antibody treatment should be postponed until after delivery. Chemotherapy is allowed after the first trimester. Breast cancer in pregnancy is an uncommon phenomenon but one which poses dilemmas for patients and their physicians. A multidisciplinary approach is recommended for optimal clinical decision making. But physicians should be aggressive in the workup of breast symptoms in the pregnant population to expedite diagnosis.

[Diagnosis of cervical squamous intraepithelial lesions by fluorescence imaging: clinical feasibility study]. / Diagnostic des lésions malpighiennes intraépithéliales par colposcopie en fluorescence: étude de faisabilité clinique.

OBJECTIVE: Fluorescence diagnosis is still undeveloped in gynaecology. In order to diagnose and localize squamous intraepithelial lesion (SIL) of the cervix, a new method improving the low specificity of colposcopy would be useful. The goal of this study was to assess the feasibility and safety of colposcopic fluorescence diagnosis of SIL after topically application of methyl aminolevulinate (MAL). PATIENTS AND METHODS: Patients with histologic proved cervical intraepithelial neoplasia (CIN) and planned for loop electrosurgical excision procedure (LEEP) under general anesthesia were included in a prospective study. Before general anesthesia, a thick layer of MAL (Metvix-160 mg/mL cream) was applied on the cervix for 35-150 min. Fluorescent colposcopic inspection of the cervix was performed using a rigid 10-mm laparoscope inserted in the vaginal cavity and connected to D-light AF system (Karl Storz Endoskope, Tuttlingen Germany). In order to confirm neoplasic status, fluorescent foci underwent directed punch biopsy(ies). RESULTS: Fourteen patients were included in the study. Colposcopic fluorescence imaging revealed red fluorescent foci in 71.4% of cases (10/14) (neoplasic status of fluorescent foci was confirmed in 80%). Concerning MAL, the mean of application time was 73 min (35-150). Two cases presented a false-positive fluorescence and four cases of false-negative fluorescence. For all cases of false-negative fluorescence, application time of MAL was less than 60 min. We observed no systemic or local toxicity of MAL application in any group. DISCUSSION AND CONCLUSION: Using topical application of MAL to the cervix, we demonstrated that fluorescence diagnosis of SIL is feasible. This study justifies the further development of fluorescence imaging that combines classical white light colposcopy with the use of a photosensitizer.

[Diagnosis of vulvar intraepithelial neoplasias (VIN)]. / Diagnostic d'une néoplasie intraépithéliale vulvaire (VIN).

Vulvar pathology is located at the border between dermatology and gynaecology. The gynaecologist is concerned by VIN (vulvar intraepithelial neoplasia) lesions as patients meet them for that problem. He makes distinction with dermatologic lesions so as to refer proper patients to dermatologists. A recent classification of VIN has a major interest. One individualizes two kinds of precancerous lesions. The first one is lichen sclerosis with dermatologic treatment by dermocorticoids and the other aetiology is HPV infection with frequent association with cervical localisation. Gynaecologists are more familiar with this second aetiology. Thus, they have to (i) check for VIN, (ii) know their appearance and how the diagnosis can be made by biopsy, (iii) precise the aetiology, (iv) appreciate the severity of the disease, (v) discuss which treatment is indicated: destruction or surgery.

[Surgical therapeutic management for menorrhagia]. / Thérapeutique chirurgicale des pathologies fonctionnelles.

In patients with dysfunctionnal uterine bleeding, endometrial hypertrophy or endometrial hyperplasia without atypie, the curettage is the only surgical conservative treatment which allows preservation of fertility. Its efficacy is limited to about 50%. In women without wish for further childbearing, endometrial destruction techniques are effective with high satisfaction levels. Second generation devices should be preferred because they are as effective as first generation techniques, but are easier and faster to perform with less complications. There is no indication for systematic use of pre operative thinning agents. Endometrial destruction techniques are an alternative to hysterectomy that should be offered to women with heavy menstrual bleeding, because there are shorter operation time and hospital stay, earlier recovery and reduced post operative complications. The possibility of further surgery should however be discussed pre-operatively. In case of hysterectomy, abdominal route is not recommended, and vaginal or laparoscopic routes are preferred.

[Ovarian dermoid cyst complicated by chemical peritonitis. Case report]. / Kyste dermoïde de l'ovaire compliqué d'une péritonite chimique. A propos d'un cas.

Dermoid cyst is the most frequent benign ovarian tumor. Its spontaneous or more frequently iatrogenic intraperitoneal rupture may lead to a chemical peritonitis. This is a rare complication but with a potentially dangerous issue. We report a case of a patient who developed chemical peritonitis after laparoscopic management of ovarian dermoid cysts. Three further interventions, associated with systemic anti-inflammatory treatment, were necessary to resolve symptoms completely. On the basis of this case, we aim to re-access the characteristics of dermoid cysts and highlight in particular the potential complication of chemical peritonitis and the following attitude to avoid this.

[Laparoscopic management of occult cervical cancer discovered after simple hysterectomy]. / Prise en charge chirurgicale par voie d'abord coelioscopique du cancer du col utérin occulte découvert après hystérectomie simple.

OBJECTIVES: To assess the feasibility and morbidity of surgical management by combined laparoscopic and vaginal approach after cervical cancer diagnosed at the time of simple hysterectomy. PATIENTS AND METHODS: From 2000 to 2005, 10 patients were referred with occult cervical cancer discovered after simple hysterectomy. All these patients had laparoscopy for surgical staging. RESULTS: Eight on ten patients had complete laparoscopic staging: pelvic lymphadenectomy (N=8), radical colpectomy (N=5). Operative time, pelvic lymph nodes resected, postoperative stay were respectively 261.3 minutes (200-400), 27 (23-38), 4.4 days. There were 2 symptomatic lymphocysts. Pelvic lymph nodes were positive for 1 patient with negative paraaortic nodes. Residual disease was present in 2 cases: 1 parametrial and vaginal involvement, 1 ovarian metastasis. 5 patients had adjuvant treatment: 2 combined pelvic external radiotherapy and brachytherapy, 1 pelvic external radiotherapy, 1 pelvic concurrent chemoradiation and 1 brachytherapy only. Two on ten patients needed a laparoconversion, one for ovarian involvement and one for technical failure. With a median follow-up of 29.7 months (4-63), 3 patients recurred. 3 patients recurred above 5 patients with pelvic lymphadenectomy but without parametrectomy versus no recurrence above 5 patients with pelvic lymphadenectomy and parametrectomy. DISCUSSION AND CONCLUSION: Surgical staging of occult cervical cancer discovered after simple hysterectomy is necessary for indication of adjuvant treatment. Laparoscopy combined with vaginal surgery is feasible and safe, inducing fewer adhesions which is important for adjuvant radiotherapy. The realization of a radical parametrectomy seems to offer a local control of the disease and a decrease in the risk of recurrence, which need to be confirmed by conducting a study with more patients. This emphasize the necessity of creating a national record to register all women managed for occult cervical cancer.

[The place of photodynamic therapy in gynecology]. / Intérêt et place de la thérapie photodynamique en gynécologie.

Photodynamic therapy (PDT) is a specific anticancer treatment that received significant interest in several medical and surgical disciplines. The technique is based on (i) the application of the photosensitizer that accumulates in a variable time in the neoplasic lesions and on (ii) excitation (by light whose wavelength coincides with the absorption peak of the photosensitizer) that (iii) finally causes the destruction of the lesion. This technique allows a minimally-invasive, effective and targeted treatment of some gynecological diseases. Experimental and/or clinical studies have been conducted on vulvar intraepithelial neoplasia, cervical intraepithelial neoplasia, ovarian cancer, breast cancer, dysfunctional uterine bleeding, endometriosis and vulvar lichen sclerosus. We aim to present the principles of PDT and to expose the main indications and ways of research of this technique in gynecology today.

[Intraperitoneal chemotherapy in ovarian cancer]. / Chimiothérapie intrapéritonéale dans le cancer de l'ovaire.

Ovarian cancer represents 4500 new cases a year in France and the prognosis of such tumor is not yet clear, even for the early stages. This is notably owing to the amount and size of peritoneal tumor residual. Recently, five therapeutic trials were published concerning the intra-peritoneal chemotherapy of ovarian cancer stage III in patients to whom an optimal debulking surgery had been done. These studies were variable in there outcome showing on the one hand, either the absence of significant difference or a significant lengthening of both total life duration and life without recurrence during the period of treatment with intra-peritoneal chemotherapy. On the other hand, there was a significant increase in hematological toxicity and temporary impairment of the quality of life during intra-peritoneal treatments. There were also complications linked to the intra-peritoneal catheter, which led to the termination of the treatment protocol in some cases. However, results showed a mattering benefit of survival in spite of a notable rate of incomplete treatment protocols. These results have demonstrated the necessity to consider the intra-peritoneal adjuvant chemotherapy as a treatment option in patients with epithelial ovarian cancer stage III. Patients must be highly selected and well counseled, in order to go for this treatment option after receiving optimal debulking surgeries.

[Malignant ovarian germ cell tumours: a trial of 36 cases]. / Tumeurs germinales malignes de l'ovaire. A propos de 36 cas.

OBJECTIVE: With personal results and a review of the literature, we report the eventual interest of surgical staging in malignant ovarian germ cell tumours. PATIENTS AND METHODS: This was a retrospective study of 36 patients (21.5-[8-61]) with malignant ovarian germ cell tumours between January 1984 and December 2004. There were 4 groups: no 1--dysgerminoma only, no 2--immature teratoma, no 3--malignant ovarian germ cell tumours with secretion. All the patients had a minimal follow up of 18 months after treatment. We reported conservative or non-conservative surgery, if surgical staging was made and description of eventual neoadjuvant or adjuvant chemotherapies and finally the recurrences and deaths. RESULTS: Stages of FIGO were: group 1--IA n=2, IC n=2, IIB n=1, IIIA n=2, IIIC n=3; group 2--IA n=3 (G1, G2, G2), IC n=1 (G3); group 3--IA n=8, IC n=4, IIA n=1, IIIA n=1, IIIB n=3, IIIC n=5. Three patients had neoadjuvant chemotherapy. All the patients had cytoreductive surgery (conservative surgery n=31) with staging in 15 cases. Twenty-six patients had adjuvant chemotherapy. Five years global survival was 92%. DISCUSSION AND CONCLUSION: Surgery in a young patient with malignant ovarian germ cells tumours must be conservative (adnexectomy) (preserving fertility and because of good prognostic). In case of stage IA with part of dysgerminoma and/or immature teratoma and/or embryonal carcinoma certified by surgical staging, strict follow up could be organized (clinic, radiology, AFP, HCG). In case of more than stage IA, chemotherapy is indicated after conservative surgery and surgical staging.

[Interest in agents for adhesion prevention after gynecologic surgery]. / Intérêt des produits antiadhérentiels en chirurgie gynécologique.

Adhesion barriers are intraperitoneal agents, solid or fluid, developed in order to prevent postoperative adhesions. In this article, we evaluate the efficiency of these new barrier agents for adhesion prevention in gynaecologic surgery, undertaking a review of controlled clinical trials published. Several human clinical trials demonstrated the safety and efficiency of both Interceed and Seprafilm. As far as other barrier agents are concerned, data are still insufficient to recommend them for clinical use. There is a need for other randomised controlled trials in order to evaluate functional efficiency of anti adhesion agents.

[Tubal choriocarcinoma: a case report and review of the literature]. / Choriocarcinome tubaire: à propos d'un cas et revue de la littérature.

The authors describe a case report of a tubal choriocarcinoma occurring in women of 32 years old, 2 years after her last pregnancy. The patient was treated by laparoscopic salpingectomy and polychemotherapy. Metastatic pulmonary micronodules were diagnosed at thoraco-abdomino-pelvic tomodensitometry. Patient's recovery was complete with an uneventfull follow-up at 3 years. The association of surgical treatment and chemotherapy used under the guidelines of the FIGO score improves patient's outcome.

[Ovarian cancers and CA 125 in 2006]. / Tumeurs de l'ovaire et CA 125 en 2006.

The authors propose to report progress on the use of the CA 125 serum assay. It affects three situations: screening, diagnosis and the follow-up of the patients dealt with ovarian tumour either of benign or malignant nature. For each situation the interest and the relevance of CA 125 assay will be approached.

[2005 monitoring report: use of positron emission tomography with fluorodeoxyglucose in the management of patients with breast cancer, ovarian cancer, and uterine cancer]. / Bulletin de synthèse de veille 2005: recommandations pour la pratique clinique: utilisation de la TEP-FDG dans les cancers du sein, de l'ovaire et de l'utérus.

CONTEXT: The validity of the recommendations is based on their actualisation as well as on the quality of the initial elaboration process. Therefore the "Standards, Options and Recommendations" (SOR) from the National French federation of comprehensive cancer centres (FNCLCC) has set up a literature monitoring process. OBJECTIVES: To identify new data, which are likely to modify existing recommendations, evaluate their impact and inform potential users on their validity. METHODS: The monitoring process is based on 3 main steps lead in collaboration with experts: collect data, select and classify information and analyse information. Analysis of information consists of comparing the conclusions of new data with the conclusions of the initial report and then to identify the recommendations that need to be updated. RESULTS: This article presents the 2005 monitoring report concerning "the use of positron emission tomography with FDG in the management of breast cancer, ovarian cancer and uterin cancer". Following the monitoring process,all the existing recommendations (initial report from 2003) are still valid. However three modifications have been proposed by the working group: 1) increased level of evidence concerning the use of PET-scan for suspicion of local or metastatic recurrence (option, level of evidence: A); 2) a new option for the use of PET-scan for revealed cervix cancer recurrence, especially for the therapeutic decision strategy (level of evidence: B2); and 3) new formulation (less strict) of the recommendation concerning the use of PET-scan in the management of endometrial cancer.

[Endometriosis and infertility]. / Endométriose et infertilité.

Relationship between infertility and endometriosis is still controversial. Many mechanisms have been reported such as anatomical disorders, biologic and cytological modifications of peritoneal liquid, functional ovarian and endometrial disorders, reduced embryo quality. Management of infertility related to endometriosis is difficult and no consensus has been published yet. Following recent clinical data, therapeutic strategies are discussed.

[Management of endometriosis of the urinary tract]. / Prise en charge de l'endométriose urinaire.

Endometriosis of the urinary tract (bladder and/or ureter) is rare and concerns 1-2% of cases of endometriosis. Surgical management is usually mandatory. Rate of peri operative morbidity is low. There is a risk of functional (dysuria, chronic hypogastric pains, imperiosity) and anatomical recurrences (0-15 and 0-10% respectively). Surgical treatment of bladder and/or ureteral endometriosis requires informed consent of patients and multidisciplinary management.

[Immunological aspects of ovarian cancer: Therapeutic perspectives]. / Aspects immunologiques du cancer de l'ovaire : perspectives thérapeutiques.

Ovarian cancer is recognized by the immunological system of its host. Initially, it is effective to destroy and eliminate the cancer. But gradually, resistant tumor cells more aggressive and those able to protect themselves by inducing immune tolerance will be selected. Immunotherapy to be effective should consider both components of immune response with an action on cytotoxic immune effectors and action on tolerance mechanisms. The manipulations of the immune system should be cautious, because the immune effects are not isolated. A theoretically efficient handling may simultaneously cause an adverse effect which was not envisaged and could neutralize the benefits of treatment. Knowledge of tolerance mechanisms set up by the tumor is for the clinician a prerequisite before they prescribe these treatments. For each cancer, the knowledge of its immunological status is a prerequisite to propose adapted immunological therapies.

What can the operator actually feel when performing a laparoscopy?

The designing of a laparoscopic simulator, particularly the parameterizing of a force feedback system, has drawn attention to the question of characterizing laparoscopic gestures and effecting quantitative measurement of the various interactions between the organs and the instruments used to operate in the case of animals. These measurements use an instrument previously developed by the authors' team. Laparoscopic gestures are characterized by a visual component and a haptic component. The visual component cannot, of course, be disregarded. The amplitude of the forces generated by interaction between organ and instrument in relation to that of the forces linked with other mechanical phenomena interfering with somesthesic information, such as friction of the operative instrument in the trocar or resistance of the abdominal wall to tilting movement, has led to a discussion about the extent of haptic components involved in the performance of laparoscopic gestures. After describing the measurement's device and the different forces applied on the surgical instrument, the authors describe the measurement of the rubbing strengths caused by the slippage of the instrument in the trocar and one of the elastic torques induced by the abdominal wall when the trocar in slanted. Comparison of values with those obtained during interactions with various organs shows that during some delicate surgical gestures, the influence of the instrument can disturb the haptic sensation. Interference of haptic sensation is greatest at maximal tilting angles and at maximal velocity of insertion and removal movement.