Surgical management of primary tumors in metastatic breast cancer review of literature

The local control of the primary breast cancer in metastatic patients yields a survival benefit attributed to the reduction of the tumor cell load and activation of the immune system. Clinical studies do not firmly support this theory and oncologists and oncological surgeons are facing dilemmas in the management of these patients. In this paper, we review the optimal patient profile as well as the type and timing of surgery for primary tumor resection of metastatic breast cancers

Pregnancy and renal transplantation

Pregnancy is common nowadays in kidney transplant female patients because of medical and surgical advances. However, pregnancy is a high risk one in these patients. Fertility is rapidly restored after the transplantation; thus, contraception is a good option in the first year. Adding to that, pregnancy can endanger the allograft function in the presence of hypertension, a moderate to severe kidney disease and proteinuria. Medical complications are more prevalent in kidney transplant population, such as infections, gestational hypertension and diabetes and anemia. Low birth weight infants and premature delivery are two other major concerns in this population. Acute rejection of the allograft is another major complication that can be avoided with close monitoring of the graft and convenient immunosuppression. Immunosuppressive drugs must be continued during pregnancy except for mycophenolic acid and sirolimus that can be teratogen. Delivery of kidney transplant patients should be vaginal and spontaneous. Cesarean section should be reserved for obstetrical indications. Prophylactic antibiotics should be administered for every invasive procedure. Patients treated with corticosteroids can breastfeed their babies. Kidney donating women can have a safe pregnancy but with a slight risk of gestational diabetes and hypertension. In summary, a multidisciplinary medical team should follow pregnant kidney transplant patients in a tertiary center. International and national registries are a must to collect data concerning this particular high-risk population in order to solve unanswered questions

[Infertility and kidney transplantation]

Renal failure impairs the endocrine system, especially in women, due to hyperprolac-tinemia, altering fertility, ovulatory cycles, libido and growth in adolescents. Renal transplantation is considered the best solution to the problems of renal failure and and of dialysis, as evidenced by comparing the rate of hyperprolactinemia [100% in chronic renal failure, 60% in patients on dialysis and 35% in posttransplantation]. Kidney transplant is less efficient for restoring perfect function of the hypothalamic-pituitary-gonadal axis due in part to the immunosuppressant regimens prescribed. When these drugs are properly managed, transplantation will restore near normal sexual function

Living donor nephrectomy : Open vs laparoscopy. Renal function and complications

This study is to compare the short and long-term renal function between adult recipients of living laparoscopic and open donors [LR vs OR] to highlight the effect of the surgical technique on graft function. Moreover, we chose to compare the organic [hypertension, proteinuria, serum creatinine] and psychological [aspect of libido, need for anxiolytics] long-term effect of the surgery between laparoscopic and open donors [LD vs OD]

Methods: After census of adult recipients and living donors between 2003 and 2012, and after application of exclusion criteria and selection of homogeneous groups of donors and recipients, a retrospective cohort study was conducted between October 2008 and January 2012. In recipients, renal function in the short term was reported by the value of serum creatinine at +/- D5 post-op and the long-term values of serum creatinine at 6 and 12 months after surgery. Delayed graft function was defined by a serum creatinine value >/= 2.5 mg/dl on D5 post-op. A questionnaire for donors was established

Results: The two groups OR and LR were homogeneous concerning age, sex and body mass index [BMI]. Different groups OD and LD, chosen according to the variable of interest, were made homogeneous. Despite a different warm ischemia time between the 2 groups [175.54 seconds in LR vs 44.67 seconds in OR, p < 0.001], renal function in the short- and long-term in recipients was not statistically different [At day 5, 1.54 vs 1.50 mg/dl, p = 0.781; at 6 months, 1.37 vs 1.38, p = 0.871; at 12 months, 1.34 vs 1.36, p = 0.569, in OR and LR respectively]. Similarly, there was no significant statistical difference concerning organic and psychological complications between OD and LD except for a shorter period between hospital discharge and return to work in LD

Conclusion: In our center, renal function in the shortand long-term was similar in OR and LR. Apart from the advantages offered by the laparoscopic technique, organic and psychological long-term effects were similar between OD and LD. Nevertheless, laparoscopy seemed to facilitate kidney donation and is requested by almost all living donors independently of their social status

Cytomegalovirus infection post kidney transplant: What should we know now

Cytomegalovirus [CMV] remains one of the most important pathogen responsible for the morbidity and mortality of transplantation patients. The impact on recipients depends on the form of CMV infection knowing that 10% to 50% develop symptomatic disease while solid organ involvement if presumed [e.g. CMV nephritis] may have deleterious outcome and requires histopathology testing. Treatment with antivirals IV ganciclovir and valganciclovir is managed according to early diagnostic tools with quantitative nucleic acid testing [QNAT] and antigenemia that will indicate the extent of disease and monitor response to treatment. CMV prevention in particular conditions of high risk patients has proven to be beneficial, resistance to antivirals and CMV vaccines along with novel therapies are thoroughly discussed in this review describing the new perspectives of CMV infection management

Cerebral aneurismal rupture with subarachnoid hemorrhage during pregnancy: a case report

Background: Intracranial hemorrhage due to arteriovenous malformation or intracranial aneurysm is a rare but severe complication of pregnancy with maternal and fetal mortality of 20% and 33% respectively. Whether to deliver the patient first, or to treat the aneurysm first is still controversial, but an emergency cesarean section followed by aneurismal treatment appears to be a widely accepted strategy in pregnant women with cerebral aneurysmal complications

Case: A 38-year-old patient, G3P2A0, presented at 36 gestational weeks with a diffuse bilateral subarachnoid hemorrhage with fourth ventricle bleeding and hydrocephalus. She had a cerebral aneurysm of the left posterior communicating artery on arteriography. A cesarean section was performed on the first day of admission, and an external ventricular derivation with clipping of the aneurysm on the left posterior communicating artery were done immediately after the cesarean section. Mother and newborn were discharged from hospital in a good health status except Broca's aphasia in the mother

Conclusion: In the absence of categorical recommendations, we stress the role of combined care by both neurosurgeons and obstetricians, on a case to case basis according to gestational age, mother neurological status and experience of caregivers

Laparoscopic treatment of vaginal agenesis: Three cases

Ninety per cent of cases of con- genital vaginal agenesis are represented by the Mayer- Rokitansky-Kuster-Hauser syndrome, the remaining 10% being represented by the testicular feminization syndrome and vaginal aplasia. Numerous surgical methods for the treatment of vaginal agenesis have been described. Neovagina construction by sigmoid colpoplasty seems to be the best surgical option as regards the anatomical and functional out- come. We report the case of three patients oper- ated of neovagina construction with a sigmoid graft by a laparoscopic-perineal approach. The surgical intervention lasted for 330 minutes, 210 minutes and 150 minutes respectively for the three patients. There were no perioperative complications. The duration of hospitalization was respectively 7, 4 and 6 days. The length of the neovagina was 15, 14 and 18 cm without retraction on the follow-up at 2 and 6 months. The vaginal wall maintained its paten- cy allowing normal intercourse. The patients had normal sexual life after the surgery. Our results demonstrate the feasibility of laparoscopic-perineal neovagina construction by sigmoid colpoplasty when it is performed by experienced surgeons in gynecology and digestive laparoscopic surgery

[Complications urinaires fonctionnelles apres chirurgie uterine radicale Revue de la litterature]

Background and study objective: Radical hysterectomy is the surgery of reference for cervical cancer at an early stage. However, it causes functional urinary complications. The purpose of this article is to review the literature recalling the anatomy of the pelvic nerves and their relation to the various viscera, to better understand the etiology of urinary functional disorders associated with pelvic autonomic nerve section, and their prevention techniques

Methodology and findings: A systematic search of the medical literature and PubMed from 1950 to 2013 showed that urinary complications are mainly a decreased sensation of need, urine output and bladder compliance, an increase in residual urine volume, and a urinary incontinence. Causes include a vegetative denervation, anatomical changes causing loss of the support of the urethra and the vesical neck as well as the local trauma. The severity of vesicoureteral dysfunction is associated with the degree of radical hysterectomy. Radiotherapy can increase associated urinary morbidity of radical hysterectomy. These complications can be avoided with conservative surgery for pelvic nerves initiated by the Japanese Yabuki. In the postoperative course of a radical hysterectomy, it is important to avoid and treat bladder overdistensions, diagnose and treat any urinary tract infections that are often asymptomatic

Conclusion: Knowledge of the surgical anatomy of the nerves and their relation to other pelvic structures, allows the improvement of postoperative functional urinary outcomes

[Breast cancer: nomograms to predict pathologic response after preoperative chemotherapy]

If the benefit of adjuvant chemotherapy may be determined at the level of a population, to determine the real chemosensitivity of a tumor at the individual level is impossible. The concept of neoadjuvant chemotherapy in patients with localized breast cancer is interesting because it helps to know the chemosensitivity of a tumor "in vivo". It is possible to use a single criterion to predict the effectiveness of targeted therapies. The chemotherapy is not a targeted therapy, and to determine a biological predictive marker of the response has been impossible so far. The development of mathematical models and use of molecular biology may help to predict chemosensitivity. Initial results are promising. The validation of published works is necessary, but applications are numerous

[Skin sparing mastectomy: a revisited technique]

Skin-sparing mastectomy [SSM] is an appealing treatment option for patients with early-stage breast carcinoma. This article is a review of the literature concerning this innovative technique. Surgery consists in a total mastectomy with preservation of the cutaneous envelope of the breast. This is done by performing the smallest incision possible, e.g. periareolar incision, with ablation of the nipple-areola complex. Mastectomy is followed by immediate reconstruction with a prosthesis and/or flap. Besides complications of reconstruction, the principal postoperative concern is necrosis of the skin flap. SSM seems oncologically safe as studies didn't find any difference in terms of relapse, metastasis and survival when comparing SSM to non-SSM. Nevertheless, the use of this technique remains controversial in advanced stage breast cancer [2B and 3]. Finally, SSM is associated with improved aesthetics with a high level of surgeons' and patients' satisfaction

[Adjuvant endocrine therapy in breast cancer. Management of early-risk relapse]

The goal of adjuvant endocrine therapy for early breast cancer is to prolong overall survival and improve the quality of life of patients. Studies on breast cancer show an early peak of recurrence at two years after surgery and distant recurrences that are responsible for a significant reduction in overall survival. Tamoxifen has been the standard of adjuvant endocrine therapy in breast cancer for years, however only about half of relapses are prevented and there is an early occurrence of serious adverse events due to agonistic estrogenic activity of tamoxifen, such as an increase in the risk of endometrial hyperplasia and venous thromboembolism. The use of aromatase inhibitors is changing this standard with studies covering various clinical settings. They have shown a benefit in many situations, such as an extension of endocrine therapy by tamoxifen, sequential hormonotherapy or up-front adjuvant therapy with aromatase inhibitors