Cervical cancer screening among Lebanese women.

BACKGROUND: Cervical cancer is a very common malignancy amongst women worldwide. Pap smear is an effective and inexpensive screening test in asymptomatic women. The aim of this paper was to assess the prevalence of Pap smear screening for cervical cancer among Lebanese women and to determine associated sociodemographic and psychosocial characteristics. METHODS: This national survey included 2255 women, selected by multi-stage random cluster sampling across Lebanon. A questionnaire about practices and perceptions related to cervical cancer screening was developed based on the "Health Belief Model". RESULTS: The weighted national prevalence of "ever-use" of the Pap smear for screening purposes was 35%. Most important determinants of screening behavior were: residence within Greater Beirut, higher socio-economic status and educational attainment, marriage status, presence of a health coverage, awareness of Pap smear usefulness, knowing someone who had already done it, and a balance between perceived benefits and perceived barriers to Pap smear screening. CONCLUSION: Regular information campaigns regarding the availability and effectiveness of the test should be devised, targeting in priority the sexually vulnerable women in Lebanon. Moreover, healthcare providers should be encouraged to discuss with their patients the opportunity of obtaining a Pap smear.

Response to dual HER2 blockade in a patient with HER3-mutant metastatic breast cancer.

BACKGROUND: HER3 activating mutations have been shown in preclinical models to be oncogenic and ligand-independent, but to depend on kinase-active HER2. PATIENTS AND METHODS: Whole-exome sequencing of the primary HER2-negative breast cancer and its HER2-negative synchronous liver metastasis from a 46-year-old female revealed the presence of an activating and clonal HER3 G284R mutation. RESULTS: HER2 dual blockade with trastuzumab and lapatinib as third-line therapy led to complete metabolic response in 2 weeks and confirmed radiological partial response after 8 weeks. Following the resection of the liver metastasis, the patient remains disease-free 40 weeks after initiation of the HER2 dual blockade therapy. Immunohistochemical analysis demonstrated a substantial reduction of phospho-rpS6 and phospho-AKT in the post-therapy biopsy of the liver metastasis. DISCUSSION: This is the first-in-man evidence that anti-HER2 therapies are likely effective in breast cancers harboring HER3 activating mutations.

[Does molecular biology play any role in ductal carcinoma in situ?]. / Carcinomes canalaires in situ du sein : rôle potentiel de la biologie moléculaire.

The natural history of ductal carcinoma in situ (DCIS) is not fully elucidated, but it is recognized that DCIS is the true precursor of invasive carcinoma. Studies could show that DCIS is as heterogeneous as invasive ductal carcinoma, yet, they were unable to predict which DCIS will progress to invasion. Several biomarkers were also demonstrated to have a certain prognostic value. However, except for estrogen receptors and HER2, biomarkers are not yet widely used in clinical practice since their predictive value has not proven to be better than the grade and the classical classifying systems of DCIS. Identifying biomarkers for risk of invasiveness in DCIS could be of great value to help high risk patients through the management of their disease and to avoid overtreatment in low risk patients.

Clear margins for invasive lobular carcinoma: a surgical challenge.

BACKGROUND: The main goal of breast conservative surgery (BCS) is the complete removal of cancer with clear margins and no deformity of the breast. However, in invasive lobular carcinoma (ILC) this goal is hard to achieve because of the underestimation of tumor size. Our study was the first to show the role of surgical techniques in the achievement of clear margins for ILC. METHODS: We reviewed 73 patients with ILC who underwent BCS at Paris Breast Center between January 2005 and June 2008. Full thickness excision (FTE) was performed in a routine basis and oncoplastic surgery (OPS) upon tumor location, volume ratio and overall density of the breast. Margin status was evaluated as positive, close or clear. RESULTS: Positive/close margins were found in 39% of cases and were lower than what was described in the literature (49-63%). FTE was performed in 47 (64%) patients and OPS in 26 (36%) patients. No positive/close margins were observed in patients with lesions located in the lower/central quadrants. Multivariate analysis showed multifocality, larger tumor size and FTE to be independent risk factors for positive margins at final surgery. CONCLUSIONS: Our rate of positive/close margins for ILC was lower than what was described in the literature. The determinant key difference was in our surgical procedures with FTE or OPS differing from the standard BCS described in the literature and we suggest that OPS is to be considered for ILC. It allows larger breast conservative surgery with good cosmetic results and lower rate of compromised margins.

Accuracy of stereotactic vacuum-assisted breast biopsy with a 10-gauge hand-held system.

OBJECTIVE: The aim of this study is to evaluate the accuracy and the safety of stereotactic vacuum-assisted breast biopsy with a 10-gauge hand-held portable system. MATERIALS AND METHODS: Retrospective data review of 288 consecutive breast lesions that underwent stereotactic 10-gauge hand-held portable vacuum-assisted biopsy from October 2004 through March 2006, was performed. The mean number of core specimens and the percentage of complete radiological removal of the target lesion were analysed. ADH and DCIS under-estimation were evaluated, as were the immediate and delayed complications due to the procedure. RESULTS: The mean number of core specimens obtained per procedure was 9 (range 4-24). Complete radiological excision of the target lesion was achieved in 31.6% (91 of 288) with 91% of these lesions smaller than 10mm (mean size 7 mm; range 4-20mm). Under-estimation of ADH and DCIS was 18.2% (2 of 11) and 19.2% (9 of 47), respectively. There was no false negative result within a 3-year follow-up (from 2005 till date). Complications were mild and consisted of immediate bleeding and delayed haematomas. CONCLUSION: Breast biopsy using 10-gauge vacuum system is an accurate and safe technique for sampling non-palpable breast lesions.

Pain and complications of directional vacuum-assisted stereotactic biopsy: comparison of the Mammotome and Vacora techniques.

OBJECTIVE: The aim of our study is to compare the Mammotome and Vacora methods of stereotactic directional vacuum-assisted biopsy in terms of pain and complications. MATERIALS AND METHODS: From June 2001 to May 2005, 1114 consecutive patients underwent directional stereotactic vacuum-assisted breast biopsy (DVAB) for nonpalpable mammographically detected breast lesions (BI-RADS 3, 4 or 5). Respectively 967 and 147 patients underwent the Mammotome and Vacora procedures. Pain was evaluated with a visual analog scale. Immediate and late complications were recorded. RESULTS: The mean+/-S.D. (range) pain scores in the Mammotome and Vacora groups were 1.7+/-1.8 (0-9) and 2.9+/-2.3 (0-10), respectively (p<0.001). Patient age and operator experience were the main determinants of pain. Immediate complications were significantly more frequent in the Mammotome group (p=0.003), and so were late hematomas (p=0.04). Moderate and severe complications occurred exclusively in the Mammotome group. CONCLUSION: The Mammotome technique is associated with a higher risk of immediate and late complications, while the Vacora technique is associated with more frequent severe pain. Patient age was the major factor influencing pain. Further prospective studies are needed to clarify factors incriminated in pain or complications after DVAB procedures.

Risk of breast cancer associated with papilloma.

OBJECTIVE: The purpose of this study was to investigate the risk of carcinoma in patients with a diagnosis of papilloma of the breast made on ultrasound large core biopsy or stereotactic vacuum-assisted biopsies. MATERIAL AND METHODS: This retrospective database review (2000-2007) included 130 patients with a papilloma diagnosed on preoperative biopsies or excisional surgery specimen. The mean patient age was 52 years (range, 20-80 years). The examinations included mammography and ultrasonography in all 130 patients. The final surgical histology was compared to preoperative biopsy diagnosis, and then factors associated with underestimation of malignancy were evaluated in univariate and multivariate analyses. RESULTS: The preoperative histology was available for 63 patients. Benign papilloma had been identified by ductography in 34 patients and by preoperative biopsy in 48 patients. Mammography showed microcalcifications in 25 cases and nipple discharge was present in 59 patients. Malignancy was found on final histology in 8% of patients with initial diagnosis of benign papilloma. In this study group, age of more than 50 years, presence of nipple discharge and microcalcifications were found to be significantly related to the risk of malignancy (p=0.001, 0.05 and 0.02, respectively). CONCLUSION: Since benign papilloma can be associated to malignancy at excisional biopsy, we still recommend surgical excision for papilloma especially when associated to identified risk factors of malignancy.

The sentinel lymph node procedure for patients with preoperative diagnosis of ductal carcinoma in situ: risk factors for unsuspected invasive disease and for metastatic sentinel lymph nodes.

BACKGROUND: Occult invasive disease could be found at definitive histology in patients initially diagnosed with large ductal carcinoma in situ (DCIS). Sentinel lymph node (SLN) biopsy is a reliable and minimally invasive procedure providing axillary information and avoiding a second operation in this particular group of patients. The aim of our study was to assess the value of SLN biopsy in patients with large DCIS who are at highest risk for being upstaged to invasive carcinoma. PATIENTS AND METHODS: The study included 195 patients diagnosed with DCIS upon initial core biopsy and undergoing SLN biopsy. Many features were correlated with the presence of unsuspected invasive disease and positive SLN biopsy using univariate and multivariate analyses. RESULTS: Of the 110 patients with pure DCIS, seven patients (6%) had a metastatic lymph node; 31 patients (16%) were found to have invasive disease upon final histology. Univariate analysis of predictors of unsuspected invasive carcinoma showed that patients having a preoperative biopsy that indicated DCIS with microinvasion (DCISM) or large DCIS were at a higher risk of invasive carcinoma after histological examination of the operative specimen. Of the 31 patients who were upstaged to invasive carcinoma at final histology, seven patients (22%) had a positive SLN biopsy. The analysis of predictors of positive SLN in our study shows that diffuse DCIS requiring mastectomy is the main risk factor for SLN metastasis. CONCLUSION: There are no real predictive factors for invasive disease in patients with an initial diagnosis of DCIS or DCISM. Our study supports the value of SLN biopsy in patients with a preoperative DCISM biopsy or patients with a large pure DCIS biopsy requiring mastectomy.

Unscarred uterine rupture--case report and literature review.

BACKGROUND: Spontaneous uterine rupture is a life threatening event, and the diagnosis is difficult in an unscarred uterus. Many factors can help prevent the catastrophic consequences. CASE: A 38-year-old multipara in labor was admitted at 39.5 weeks of gestation. Ultrasound suggested a macrosomic fetus but the cervix was well dilated. Labor was immediately monitored. Two hours later, the fetus developed progressive heart rate decelerations. While evaluating the unexplained anomaly, epigastric pain and vaginal bleeding prompted emergency cesarean delivery. The uterine tear was repaired with good evolution but the infant died a few days later. CONCLUSION: The association of multiparity, uterine distension and active labor could be considered as risk factors of uterine rupture in cases of unexplained anomalies in an unscarred uterus, making a catastrophic event preventable.

Diagnosis and management of adenocarcinoma of the ampulla of Vater during pregnancy.

BACKGROUND: Cancer of the biliary tract has a poor prognosis and its association with pregnancy is uncommon. Early diagnosis allowing curative surgical resection offers the only hope of long-term survival. CASE: This report describes the case of a young 26-week-pregnant woman admitted for cholestatis documented by clinical and laboratory examination. Ultrasonography (US) and magnetic resonance cholangiopancreatography (MRCP) were indicative of common bile tract obstruction. Caesarian section was performed at 32 weeks of pregnancy and the tumor was promptly biopsied. Histology demonstrated carcinoma of the ampulla of Vater. The patient underwent a Whipple procedure. Both mother and baby survived. CONCLUSION: Pregnant patients with digestive cancer require careful management. Acute non-invasive assessment and radical surgery improve outcome for both the mother and fetus.

Intrauterine brain teratoma: a case report of imaging (US, MRI) with neuropathologic correlations.

Fetal brain tumors are rare and teratoma is considered as the most common. Fetal MR Imaging is currently used to evaluate cases of ventricular dilatation. We report a case of cerebral immature teratoma detected by ultrasonography because of ventricular dilatation at 24 gestational weeks. MRI was the more accurate imaging method in depicting the tumor and its consequences on brain development as well as in taking a decision with regard to the management of pregnancy.

[Effects of hormone replacement therapy for menopause on prognostic factors of breast cancer]. / Effets des traitements hormonaux substitutifs de la ménopause sur les facteurs pronostiques des cancers du sein.

AIM: Hormone replacement therapy (HRT) is widely used by post-menopausal women. Although this treatment may slightly increase the incidence of breast cancer, more and more cases are diagnosed while women are taking HRT. The purpose of this study was to ascertain the influence of HRT on prognostic factors and outcome of breast cancer. Data on all breast cancer patients, including precise information on HRT, was prospectively and systematically recorded in a data base. PATIENTS AND METHODS: From 1990 to 1998, 1223 post-menopausal women fulfilled the eligibility criteria for this study. The clinical features, laboratory findings and survival rates in 245 HRT users who developed breast cancer while being treated were compared with those of 245 matched breast cancer patients who had never received HRT. RESULTS: Patients who developed breast cancer during HRT had fewer locally advanced cancers and smaller and better-differentiated cancers. Estradiol receptivity was quantitatively lower in users. Metastasis-free survival were better for the users. CONCLUSION: We conclude that HRT does not affect the prognosis of breast cancer. Regular surveillance during HRT allows early detection of smaller lesions. The higher number of well-differentiated cancers and the distribution of hormone receptivity may reflect interaction between neoplastic tissue and exogenous hormones.

Mathematical relationships between uterine contractions, cervical dilatation, descent and rotation in spontaneous vertex deliveries.

OBJECTIVE: To determine the mathematical relationships between the strength and duration of the uterine contractions, the descent and rotation of the fetal head and the degree of cervical dilatation in 50 multiparous women with spontaneous vaginal deliveries using a simple device applied to the fetal vertex. METHOD: A simple device for monitoring the progress of labor was applied to the fetal vertex. The device allows the continuous monitoring of descent and rotation of the fetal head. The amount of descent and the degree of rotation were also determined by repeated vaginal examinations as well as the degree of cervical dilatation. The frequency of uterine contractions was also recorded on a partogram. RESULT: A good correlation was found between the amount of descent of the fetal vertex (r = 0.975) and between the degree of rotation of the fetal head (0.83) determined by both methods. Multiple regression analysis was then performed and the degree of cervical dilatation in cm at any given time during the first stage of labor was found to be equal to 2.859 + 0.583 fetal head station in (cm) + 0.1983 internal rotation in degrees -0.0493 (station x internal rotation) + 0.1599 station2 + 0.3622 uterine contractions per 10 min. A nomogram was constructed allowing the calculation of cervical dilatation for a given station of the head, degree of rotation and frequency of uterine contractions. CONCLUSION: There is a defined mathematical relationship between the degree of descent and rotation of the fetal head, the degree of cervical dilatation and the frequency of uterine contractions in multiparous women with vertex presentation. The first three variables can be continuously determined by using the described device. Incorporation of the device into a reusable fetal scalp electrode allows the dual mechanical and electronic monitoring during labor with minimal vaginal examinations.

A fistula from the portal vein to the bile duct: an unusual complication of transjugular intrahepatic portosystemic shunt.

We describe a case of a portal vein bile duct fistula as a complication of transjugular intrahepatic portosystemic shunt (TIPS) placement. The patient's course was complicated by endocarditis, hemobilia, recurrent episodes of fever, and bacteremia, followed by liver transplant. The findings of fever, bacteremia (especially with Gram-negative organisms), and a decreased hematocrit after shunt placement should raise the suspicion of an infected shunt with a possible fistula.

Endocrine profiles in pediatric andrology. II. Insulin-dependent diabetic adolescents.

Seventy-five diabetic male and female children and 75 matched controls were classified according to pubertal staging. Blood samples were assayed for gonadotropins and gonadal hormones. The ultimate adult height in diabetic patients was 5 cm less than that of controls. Almost all diabetic children had a retarded bone age. Levels of serum gonadotropins and gonadal hormones did not differ markedly between diabetic and healthy children. The delay in growth and maturation was not due to hormonal failure, but probably to chronic undernutrition of body cells and failure to utilize the amino acids for protein anabolism related to relative insulin deficiency.

Red blood cells amino-acid pattern in protein energy malnutrition and the effect of oral dosing with single amino acids.

R.B.C.'s amino acid pattern was investigated in control and PEM subjects. The effect of oral dosing with cysteine, tryptophan and lysine on total amino acid nitrogen level of R.B.C.s was also studied. Results revealed that in moderate and severe kwashiorkor the total essential and non-essential R.B.C.'s amino acids were decreased. In 2nd grade marasmus the total R.B.C.'s amino acids in general showed lower values than normal. After oral administration of the tested amino acids, the transport index calculated as the level of maximum value of the total R.B.C.'s amino acids reached to the fasting level was lower in malnourished cases relative to controls except in 2nd grade marasmic cases given tryptophan or lysine. This criteria was considered to indicate lower rate of amino acid transport to R.B.C.s due to lower concentration in plasma or shift of transport mechanism from active transport to exchange diffusion.

Protein-calorie malnutrition (PCM) in Egypt immunological changes of salivary protein in PCM.

Whole saliva protein as well as the separated protein components were estimated in normal and malnourished Egyptian infants and young children. In normal, 8 protein components (Albumin, alpha1-antitrypsin, haptoglobin, beta2-lipoprotein, transferrin, IgA, IgM and IgG) were detected, while in PCM cases two more components (prealbumin and alpha2-macroglobulin) were found. The results also showed that the level of salivary protein components are markedly increased in edematous cases. In non-edeomatous ones, the level of these constituents are slightly increased in 3rd marasmus, but diminished in 2nd grade. It is concluded that the elevation of protein components in saliva of edematous cases could be a result of severe glandular tissue involvement as compared to controls and non-edematous cases. The value of IgA immunoglobulin as specific antibody originated from blood plasma and/or salivary glands may be used to reflect the extent of tissue affection in salivary glands of malnourished cases.

Salivary amino acids and proteins in normal and malnourished Egyptian infants and young children.

Amino acids and proteins in whole saliva of normal and malnourished Egyptian infants and young children were investigated. 16 amino acids, 7 of them are essential, could be detected in saliva of normal infants. Electrophoretic analysis revealed the existence of 10 protein components in saliva of either normal or malnourished infants. In oedematous cases, salivary aminoacids, particularly the essential ones, were increased as well as most of the protein components. In non-oedematous cases, the pattern was more or less normal, but in 3rd grade marasmus, amino acid and protein components of saliva were somewhat increased. The conclusion was drawn that such increase is mainly due to tissue degeneration which is more marked in oedematous than non-oedematous form of the disease.