Development of a geriatric vulnerability score in elderly patients with advanced ovarian cancer treated with first-line carboplatin: a GINECO prospective trial.

BACKGROUND: Two previous GINECO elderly specific studies in advanced ovarian cancer (AOC) patients highlighted the prognostic value of geriatric covariates for overall survival (OS). PATIENTS AND METHODS: This open-label prospective trial was designed to identify the impact of geriatric covariates on OS in AOC patients ≥70 years treated with first-line carboplatin. RESULTS: Geriatric covariates of the 111 patients included median age 79 years (≥80 years: 41%); performance status (PS) ≥2: 47%; ≥3 major comorbidities: 24%; ≥4 comedications: 68%; activities of daily living (ADL) score <6: 55%; instrumental activities of daily living (IADL) score <25: 69%; Hospital Anxiety and Depression Scale (HADS) >14: 37%. The median OS was 17.4 months. Overall, 74% of patients completed the six planned chemotherapy cycles. Grade 3-4 haematological toxic effects were frequent (50%) but manageable. Grade 3-4 non-haematological toxicities included fatigue (15%), anorexia (12%), infections (9%) and thrombosis (2%). A survival score = exp(0.327*GVS) was developed, where the geriatric vulnerability score (GVS) is the sum of the following (each assigned a value of one): albuminaemia <35 g/l; ADL score <6; IADL score <25; lymphopaenia <1 G/l; and HADS >14. With a cut-off ≥3, GVS discriminated two groups with significantly different OS, treatment completion, severe adverse events and unplanned hospital admissions rates. CONCLUSIONS: The GVS is a valuable tool for identifying vulnerable patients when treating an elderly AOC population.

Gemcitabine-oxaliplatin combination for ovarian cancer resistant to taxane-platinum treatment: a phase II study from the GINECO group.

Advanced ovarian carcinoma in early progression (<6 months) (AOCEP) is considered resistant to most cytotoxic drugs. Gemcitabine (GE) and oxaliplatin (OXA) have shown single-agent activity in relapsed ovarian cancer. Their combination was tested in patients with AOCEP in phase II study. Fifty patients pre-treated with platinum-taxane received q3w administration of OXA (100 mg m(-2), d1) and GE (1000 mg m(-2), d1, d8, 100-min infusion). Patient characteristics were a : median age 64 years (range 46-79),and 1 (84%) or 2 (16%) earlier lines of treatment. Haematological toxicity included grade 3-4 neutropaenia (33%), anaemia (8%), and thrombocytopaenia (19%). Febrile neutropaenia occurred in 3%. Non-haematological toxicity included grade 2-3 nausea or vomiting (34%), grade 3 fatigue (25%),and grade 2 alopecia (24%). Eighteen (37%) patients experienced response. Median progression-free (PF) and overall survivals (OS) were 4.6 and 11.4 months, respectively. The OXA-GE combination has high activity and acceptable toxicity in AOCEP patients. A comparison of the doublet OXA-GE with single-agent treatment is warranted.

Surgical treatment of cerebellar hemangioblastomas.

BACKGROUND: Hemangioblastomas (HBL) are uncommon tumors of the central nervous system (CNS), corresponding to 1-2.5% of all intracranial tumors. They can present sporadically or in patients with von Hippel-Lindau (VHL) disease and are most often located in the cerebellum, brainstem, and spinal cord. VHL disease is a multiple neoplasia syndrome inherited in an autosomal dominant fashion and caused by a VHL suppressor gene deletion. We present our experience in the management of patients with cerebellar HBL. METHODS: Thirty consecutive patients with cerebellar HBL were included in this study. Hospital charts, radiological images, and operative records were reviewed. Modified Rankin scores were used to evaluate the clinical course. RESULTS: Thirty patients diagnosed with cerebellar HBL were operated. Complete total resection was achieved in 93% of the cases. Postoperatively, 83% of the patients showed good functional recovery. CONCLUSIONS: HBL of the cerebellum should be resected when symptomatic or when the tumor (or a tumor-associated cyst) shows signs of enlargement. Surgical intent should seek en bloc resection to minimize intraoperative bleeding. Patients with HBLs must be tested for VHL gene mutations, and in confirmed cases, relatives should be offered genetic counseling.

[Supratentorial cavernous malformations in an Argentinian institution: experience with surgical treatment]. / Malformaciones cavernosas supratentoriales en una institucion argentina: experiencia del tratamiento quirurgico.

INTRODUCTION: Cavernous malformations are vascular malformations of the central nervous system formed by a group of capillaries not covered by pia mater and communicated to the vascular system at very low pressure with very slow flow. Surgery or radiosurgery are the treatment modalities. AIMS: To analyze our results after surgical treatment of supratentorial cavernous malformations, reviewing clinical presentation, surgical indications and postoperative complications. PATIENTS AND METHODS: Analytical retrospective study of medical records and images of patients who underwent resection of supratentorial cavernomas at FLENI from January 1996 until December 2013. RESULTS: We evaluated 51 patients, mean age 34 years, followed for an average of 30 months. In 1.96% of patients diagnosis was incidental, the rest all presented symptoms. Bleeding at diagnosis was observed in 23.52%. Total excision of supratentorial cavernous malformations was possible in all cases. The only postoperative complication was one case of meningitis. CONCLUSIONS: The bleeding rate of supratentorial cavernous malformations in our series was 1.38% per patient per year. Surgical treatment effectively eliminated, or at least reduced symptoms, prevented rebleeding, and decreased need for antiepileptic drug therapy. Surgery have a low complication rate and good outcome.

TITLE: Malformaciones cavernosas supratentoriales en una institucion argentina: experiencia del tratamiento quirurgico.Introduccion. Las malformaciones cavernosas son lesiones vasculares del sistema nervioso central constituidas por endotelio sinusoidal que forma capilares agrupados o cavernas que carecen de los elementos tipicos de una pared arterial madura y ausencia de tejido neural interpuesto. El endotelio esta rodeado por una densa capa de fibras colagenas que dejan pequeñas hendiduras por las que se extravasa hemosiderina. Se comunican con el sistema vascular a muy baja presion y su tratamiento puede ser por microcirugia o radiocirugia. Objetivos. Analizar las malformaciones cavernosas supratentoriales tratadas quirurgicamente en nuestra institucion (FLENI), determinar la epidemiologia y las caracteristicas intrinsecas, estudiar la clinica de presentacion, determinar las indicaciones quirurgicas y complicaciones, y establecer el pronostico. Pacientes y metodos. Estudio retrospectivo analitico de historias clinicas e imagenes de pacientes operados de malformaciones cavernosas supratentoriales en la FLENI desde enero de 1996 hasta diciembre de 2013. Resultados. Evaluamos a 51 pacientes, de 34 años de media, seguidos durante una media de 30 meses. El 1,96% de los pacientes presento diagnostico incidental y el resto mostro sintomas. El 23,52% presento hemorragia en el momento del diagnostico. En todas las cirugias se logro una exeresis total de las malformaciones cavernosas supratentoriales. Se observo un caso de meningitis postoperatoria. Conclusiones. La tasa de sangrado de las malformaciones cavernosas supratentoriales en nuestro medio es del 1,38% por paciente por año. El tratamiento quirurgico es eficaz para erradicar o disminuir los sintomas y para evitar un posible resangrado. Presenta una tasa muy baja de complicaciones y un pronostico neurologico favorable.

[Factors considered to choose type of a hysterectomy for benign uterus lesions (excluding prolapsus and obstetrical indications)]. / Facteurs du choix de la voie d'abord des hystérectomies pour lésions utérines bénignes (prolapsus et indications obstétricales exclus).

OBJECTIVES: We searched for the factors determining the type of hysterectomy (vaginal, laparoscopy or laparotomy) performed in women with supposedly benign uterine disease. MATERIAL AND METHOD: We conducted a retrospective study of 101 consecutive hysterectomies performed on voluminous uteruses, prolapsus and obstetrical indications excluded. The following factors likely to have influenced the decisions were examined: patient age, nulliparity, menopausal status, history of laparotomy, uterus weight, narrow vagina, nature of uterus lesions, associated unilateral or bilateral annexectomy, complications. RESULTS: The frequencies were: vaginal route 58.4% (average uterine weight 249.4 g, range 93-1149 g), laparoscopic preparation 37.6% (average uterine weight 348 g, range 92-818 g), and laparotomy 4% (average uterine weight 586.2 g, range 112-1216 g). Factors determining type of hysterectomy were uterine weight (and therefore volume) (p < 0.05), nulliparity (p < 0.04), narrow vagina probed by compulsory Schuchardt incision (p < 0.02), associated annexectomy (p < 0.01). No other factors were significantly determinant. The vaginal route appears to be highly preferred. CONCLUSION: Vaginal hysterectomy is clearly the most preferred and practiced. Laparoscopy may be helpful for vaginal hysterectomy and laparotomy is exceptional.

Feasibility of retroperitoneal pelvic lymph node exploration in cervical carcinoma. Assessment of morbidity in 33 cases treated by combined radio-surgery or definitive radiotherapy.

BACKGROUND AND PURPOSE: Laparoscopic modalities by selective biopsies permit a better assessment of the pelvic lymph nodes status than imaging procedures in cervix carcinoma. They could enable the radiation oncologist to adapt the target volume of external irradiation, provided the feasibility of such procedures is good and the toxicity reduced as much as possible. MATERIAL AND METHODS: From June 1980 to May 1993, 52 women with a mean age of 49, underwent a retroperitoneal pelvic lymph node laparoscopic procedure for cervix carcinoma classified according to FIGO as stages IA2 (14), IB (12), IIA (6), IIB (14), IIIB (3) and IVA (3). Two techniques were used: retroperitoneoscopy (RPS) in 16 cases, and a panoramic retroperitoneal pelviscopy (PRPP) in 36 cases. RESULTS: Intra-operative and post-surgical morbidity were equivalent in the two procedures. Among the 33 patients who had external irradiation, one Grade 3 urinary late morbidity (3%) due to an overtreatment was observed; no Grade 3/4 morbidity of the gastro-intestinal tract, no lymphoedema of the lower extremities, no parietal tumor cells implantation were noticed. CONCLUSIONS: These procedures can be used safely to better know the prognosis and to define the pelvic lymph node planning target volume and its radiation management with accuracy.

Pathological prognostic factors in a series of 137 stage I TNM/UICC endometrial carcinomas.

PURPOSE: We report on the long-term results of combination surgery-radiotherapy in cT1 carcinoma of the endometrium according to prognostic factors. PATIENTS AND METHODS: From 1974 to 1993, 130 women suffering from cT1Nx-O Mo endometrial carcinoma, underwent surgical resection. The median age was 62 years. Thirteen received pre-operative irradiation, two pre-operative brachytherapy followed by post-operative external irradiation and 115 patients (88.35%) underwent post-operative irradiation therapy by brachytherapy or external beam irradiation. RESULTS: The median follow-up is 67 months. Overall and specific survival rates for patients with cT1pT1 tumours were 71.1 and 85% at 10 years. For overall survival, lymph node invasion was the most powerful prognostic factor in the multivariate analysis (P = 0.02). If lymph node invasion is not taken into account, the WHO histological grade exerts a significant prognostic impact (P = 0.001). CONCLUSION: For stage cT1 endometrial carcinoma, primary surgery allows radiotherapy to be adjusted according to the WHO histological grade, myometrial invasion and the pelvic lymph node status.

Tubal sterilization by a combined laparoscopic and external technique: preliminary report on 75 cases.

A preliminary report is given on a new laparoscopic sterilization procedure. By a double-puncture method, a loop of tube is brought out of the abdomen through the suprapubic incision. The loop is then resected by a modified Pomeroy method. Between Octorber 1976 and June 1978, 75 sterilizations were performed without any major problem. Sterilization failed in one case when one tube could not be seen. All recoveries were uneventful. Safety, effectiveness, simplicity, and potential reversibility seem to be the qualities of this method.

Use of antiepileptic drugs in nontraumatic neurosurgical procedures. Is there any best route and time of administration?

We assessed in 15 consecutive patients the best route and time of administration for phenytoin (PHT) prophylaxis in neurosurgical procedures. We also correlated PHT levels in serum and cerebrospinal fluid after oral and parenteral loading doses. The mean PHT level was 13.9 micrograms/ml in serum and 2.03 micrograms/ml in cerebrospinal fluid (CSF), with a significant correlation between levels in both compartments (r = 0.73, p < 0.01). Mean PHT levels among the different groups were not statistically significant. We conclude that therapeutic levels of PHT in CSF can be achieved independently of the route of administration, as long as accepted loading doses are used.

Sacrospinous ligament fixation by palpation: variation of the Richter procedure.

OBJECTIVE: To present our method of sacro-spinous ligament fixation by palpation and compare it to the classical approach described by Richter. MATERIAL: In addition to the standard instruments needed for vaginal surgery, we use a Rasemond dissector, a small O'Shaugnessy dissector with smooth branches. We also use a Bengolea forceps and a monothread-nylon (Ethilon), decimal 4 suture loaded on a needle with a 30-mm curve. PATIENTS: Twenty patients underwent this procedure from 03/15/1978 to 05/19/1995. Their ages ranged from 46 to 86 years with a mean age of 64.7 years. METHOD: This was a retrospective study of the indications, results and complications associated with this technique. RESULTS: With an average follow-up of 7 years, we observed 90% success, 10% recurrences, and no complication directly attributable to this technique. This technique is valuable because of its effectiveness and simplicity. CONCLUSIONS: Sacrospinous fixation by palpation is more simple and provides the same results as the classic exposure technique. We describe the technique in this text. The efficacy of sacro-spinous ligament fixation by palpation would be improved by its systematic and bilateral use. Its value must be confirmed by a controlled prospective study to confirm our impression that our technique carries fewer risks.

Fast growing cervical carcinomas. A retrospective analysis of 20 IB-IIB FIGO.

INTRODUCTION: Fast growing cervix carcinomas have a pejorative outcome: they may occur quickly after cervical smears qualified as normal - within an interval from 12 to 18 months in women less than 50 years old, and involveing the endocervix. This retrospective analysis is aimed at assessing 5-year outcomes. MATERIALS AND METHODS: Twenty cases of fast-growing cancer of the uterine cervix classified according to the FIGO clinical staging system as IB (n=14), IIA (3), and IIB (3), have been reviewed and compared to a cohort of 160 cases not having this feature. As regard to fast-growing carcinoma, the median age was 41 years (range 25-50), and the median follow-up 22 months (8-213) as compared to 54 years (27-79) and 80 months (5-199) for the reference cohort. The comparison of the two cohorts shows only a difference of breakdown which concerns the histological pelvic lymph nodes status (P<0.05), more often positive in fast-growing forms. The treatment policy was equally distributed between a radio-surgical approach, cesium 137 intracavitary irradiation followed by radical hysterectomy and lymphadenectomy, or a definitive irradiation with pelvic external irradiation followed by cesium 137 intracavitary irradiation. RESULTS: Thirteen deaths are reported in the fast-growing series instead of 54 in the other series. The 5-year overall survival is, respectively, 34 (13-55) vs. 74% (68-82) (P<0.001), the loco-regional-free survival 58 (33-84) vs. 85% (79-81) (P<0.001), the 5-year metastasis-free survival 61 (38-84) vs. 84% (78-90) (P=0. 004). CONCLUSION: These poor results emphasize the need to intensify loco-regional therapy with a concurrent cisplatin-based chemotherapy within the framework of a multidisciplinary approach.

Endoscopic exploration and lymph node sampling of the axilla. Preliminary findings of a randomized pilot study comparing clinical and anatomo-pathologic results of endoscopic axillary lymph node sampling with traditional surgical treatment.

OBJECTIVE: To describe the technique of endoscopic exploration of the axilla. To compare this technique to open surgical treatment by comparing the following variables: operative time, peri-operative complications, duration of hospital stay, node's histology and morphologic aspects and esthetic results. MATERIALS: Standard instruments for traditional operative laparoscopy plus a lipo-aspirator (0.8 Bar). PATIENTS: Forty patients, 20 (group A) undergoing open surgery and 20 (group B) undergoing axilloscopy. All patients with early invasive breast cancer are eligible for conservative operative treatment. METHOD: Randomized study. The technique is described and preliminary results are presented. RESULTS: The operative time for axilloscopy is approximately double that for open surgery. A comparable number of lymph nodes is collected by axilloscopy and open surgery. The nodes collected by axilloscopy are more likely to be fractured. What is the clinical consequence? Two loco-regional relapses are observed in the endoscopic group. DISCUSSION: Axillary sampling by endoscopic procedure gives the same pathologic information than surgical axillary sampling. Anatomo-pathologic aspects of nodes and possibilities of relapses were two drawbacks of this procedure. CONCLUSION: Operative time is increased for axilloscopy compared with open surgery. The techniques yield comparable anatomo-pathologic results. It is still unknown whether this endoscopic technique is as effective as traditional surgery or if the frequency or severity of lymphedema is decreased by the endoscopic approach.

Laparoscopic treatment of cul-de-sac obliteration secondary to retrocervical deep fibrotic endometriosis.

One hundred women with cul-de-sac obliteration secondary to retrocervical deep fibrotic endometriosis (48 partial, 52 complete) were treated laparoscopically for infertility (46 cases), pain (46), hypermenorrhea (7) and a mass (1). The surgical techniques included aqua-dissection, electrosurgery, CO2 laser, scissors, probes to identify the upper posterior vagina and rectum, and multiple rectovaginal examinations. In all the procedures the anterior rectum was freed to the loose areolar tissue of the rectovaginal septum prior to excising deep fibrotic endometriosis. The viable intrauterine pregnancy rate among patients with infertility was 70% (32/46). Of patients presenting with pain, 89% (41/46) reported significant relief. The average operating time was 178 minutes. Laparoscopic cul-de-sac dissection, though time intensive, offers increased fertility potential and significant symptom relief.

[Fast growing IB-IIB cancer of the uterine cervix. Apropos of 20 cases]. / Cancers du col utérin IB-IIB à croissance rapide. A propos de 20 cas.

Twenty cases of fast growing cancer of the uterine cervix (14 IB, three IIA, three IIB FIGO), the definition of which is specified, have been reviewed and compared to a cohort of 160 cases not having this feature, to assess their outcomes. In regard to fast growing carcinomas, the median age was 41 (25-50) years and the median follow-up 22 months (8-213) as compared to 54 years (27-79) and 80 months (5-199) for the reference cohort. The comparison of the two cohorts shows only a difference of breakdown which concerns the pelvic lymph nodes status (P < 0.05, chi 2). Thirteen deaths are reported in the fast growing series instead of 54 in the other series. The 5-year overall survival is respectively 34% (13-55) versus 74% (68-82), the loco-regional free survival 58% (33-84) versus 85% (79-81) (P < 0.001), the 5-year metastasis free survival 61% (38-84) versus 84% (78-90) (P = 0.004). This particular form needs a multidisciplinary approach, and the local regional treatment has to be intensified.

[Modulation of indications of adjuvant hormone therapy with tamoxifen in T1T2/N0N1 breast cancers. Preliminary results of a multicenter study with 695 cases]. / Modulation des indications de l'hormonothérapie adjuvante par le tamoxifène dans les cancers du sein T1T2/N0N1. Résultats préliminaires d'une étude multicentrique de 695 cas.

From 1982 to 1990, patients less than 75 years, without any previous or synchonous carcinoma, suffering from an invasive breast cancer classified as T1T2/N0N1/MO according to clinical TNM staging, were enrolled in this study; 82.4% underwent a breast conservative procedure and 17.2% a modified radical mastectomy followed by a postoperative irradiation. Histological axillary lymph node status, Scarff-Bloom grade and/or cytological grade, estradiol receptor content, were used to define three groups of patients. The breakdown of patients is not well balanced: 416 women were included in group I (N-, grade I II, ER+) when there was no adjuvant medical treatment, 110 in group II (N-, grade III, ER+), 169 in group III (N+ < or = 3, grade I II, ER+). Patients from the latter two groups were receiving tamoxifene, 20 mg per day for 2 years; Those women not menopaused received first a pelvic irradiation. With a median follow-up of 35 months (1-138) the overall survival is respectively for the three groups 95%, 96%, 96% (P = 0.5) and the disease free survival 86%, 93%, 90% (P = 0.1). The actuarial local regional remission rate is 94%, 97%, 99% (P = 0.07). Such results need to be updated with a longer follow-up, but they show the ability of adjuvant hormonotherapy to tailor the short term survival thanks to prognostic factors.

[Evaluation of a series of 137 carcinomas of the endometrium of stage I TNM/UICC]. / Evaluation d'une série de 137 carcinomes de l'endomètre de stade I TNM/UICC.

PURPOSE: To assess retrospectively the long-term results of the combination of surgery and radiotherapy in carcinoma classified cT1. PATIENTS AND METHODS: From 1974 to 1993, 137 women suffering from endometrial carcinoma cT1Nx-0 M0 were entered into the study. The median age was 62 years (range: 39-85 years) and the median follow up was 67 months (range: 0-224 months). RESULTS: Surgery was performal in 132 women (96.35%). For cT1, the 5-year overall and specific survivals were 81.1% and 84.5%, respectively. The 10-year overall and specific survivals were 68.8% and 82.2%, respectively. Concerning cT1pT1, the 5-year overall and specific survivals, were 83.9% and 87.4%. The 10-year overall and specific survivals were 71.1% and 85%, respectively. Histological grade, pelvic lymph node involvement and myometrial infiltration influence significantly the overall and specific survivals of cT1pT1 tumors. According to multivariate analysis, pelvic lymph node involvement was a powerful prognostic factor for both the overall and specific survivals. If we rule out pelvic lymph node involvement, WHO histological grade was a significant prognostic factor. CONCLUSION: Combination of surgery and radiotherapy is still a common procedure for cT1 tumors. When surgery is done before radiotherapy, tailored irradiation may further take place, according to WHO histological grade and pelvic lymph node status.

[The effect of fatty emulsions with distinct triglyceride compositions on the lipid metabolism of the septic patient]. / Influencia de dos emulsiones grasas con distinta composición de triglicéridos sobre el metabolismo lipídico del paciente séptico.

OBJECTIVE: To assess the effects on the intravascular lipid mechanism of fatty emulsions with an identical lipid concentration and a different triglyceride composition administered as part of the total parenteral nutrition (TPN) in septicemic patients hospitalized in the intensive care unit (ICU). One emulsion will be made up of long chain triglycerides, LCT (20% Intralipid) (group I) and the other will be made up by a mixture of medium- and long-chain triglycerides, MCT/LCT (1:1) (20% Lipofundina) (group II). AREA: Vall d'Hebrón General University Hospital. Intensive care unit, Biochemistry laboratory, nutritional support unit, and Department of Pharmacy. PATIENTS: 12 septicemic patients who required TPN were studied, and these patients were randomly given one of the two lipid emulsions for a five day period. Prior to initiating the TPN and before ending it, blood samples were drawn for the analysis of the lipoprotein components VLDL, LDL, and HDL isolated by ultracentrifugation, and the basic lipid and nutritional parameters. RESULTS: The baseline statistical analysis shows that even though both groups are not comparable, the composition of the VLDL, LDL, and HDL lipoproteins differs from the reference values. After five days of TPN, the metabolic behavior of the groups is different, in group I the concentrations of reactive C protein (RCP) decreased as did the HDL phospholipids, while group II presented an increase in the plasma triglyceride levels, the VLDL cholesterol, the LDL triglycerides, and the HDL proteins. CONCLUSIONS: Septicemic patients present in altered lipoprotein pattern that tends to normalize after 5 days of lipid emulsions administration.

[Diagnosis and follow-up of endometriosis during consultation: changes]. / Diagnostic et suivi de l'endométriose en consultation: nouveautés.

In a literature review, news in symptomatology and follow-up of endometriosis were analyzed (infertility, pain, hemorrhage, adnexal tumors). Survey and examination can be made with improved quality (pain scale, menorragha scheme of Higham). Diagnosis and follow-up of endometriosis are more perfect by ultrasonographical examination by the gynecologist in his office. Ultrasonography is better for endometrioma and adenomyosis than other localisation (complementary explorations-magnetic resonance imaging, outside of consultation, are useful for deeper and superficial lesions). In follow-up, clinical research and ultrasonic exploration show the true relapses. Treatment's observance and success will be improved by ultrasonic analysis. Intolerances, add-back therapy, contraception, substitutive hormonal treatment of menopauses and cancer risk, are different problem and solution will be offer.

[Voluntary pregnancy termination during 1998 in a French general hospital]. / Demandes d'interruption volontaire de grossesse en 1998 dans un hôpital général en France.

The authors analyzed the etiology of voluntary abortions in a general hospital during one year. Age, family situation, nationality, children, previous abortions, type of contraception, and the reasons for aborting were reviewed. The goal is to determine the target population for effective prevention. Teenagers (7%), women under 35 years (78%), women with children (64%), primarily with two children (42%), women with poor use of contraception (pill or condom) (48%) and women without contraception (36%) were concerned. Social and cultural causes (unemployment, wedding difficulties, number of children, habitation) were often associated and different factors are described. Practitioners have little control over these sociocultural situations. A strong plan involving all the educational roles is necessary to modify this difficult situation.

[Lymph node clearing in cancer of the breast. Final results of a national survey]. / Le curage ganglionnaire dans les cancers du sein. Résultats définitifs d'une enquête nationale.

The author sent out a questionnaire to all surgeons who were likely to be operating on cancers of the breast; breast surgeons, gynaecologists and general surgeons in France. He was able to contact more than a third of all those who operate for cancer of the breast in France each year. The author analysed the present situation in regard to lymphatic clearance in cancers of the breast. He tried to establish what the indications and the technique are that are used at present. He could emphasize those where there was a consensus of opinion, areas where there was disagreement, and he was able to analyse the complications and how in the end to prevent them. The results show that axillary clearance is at present the best recognised prognostic step that can and it is virtually unanimously recognised to be effective. Axillary lymph node clearance is the most commonly practised procedure: the first two stages of Berg grade I and II are explored. It is quite clear that the nerve to the serratus anterior muscle and to the latissimus dorsalis have to be preserved. The accessory nerve to the medial brachial cutaneous nerve which supplies the internal surface of the arm should usually be preserved wherever possible to lessen the paresthesias or lack of sensation that can occur on the inner surface of the arm. Lymphocele occurs as the most common complication (12%). Internal mammary clearance is rarely carried out.