Two case reports of a malignant germ cell tumor of ovary and a granulosa cell tumor: interest of tumoral immunochemistry in the identification and management.

OBJECTIVE: In this article, we present two case reports. The first case was a malignant germ cell tumor of the right ovary in a 23-year old woman and the second case was a bilateral undifferentiated granulosa cell tumor in a 71-year old woman. The aim of these reports is to illustrate the interest of the immunohistochemical analysis to define the correct diagnosis, to better classify these ovarian tumors and improve their management. METHODS: In this study, we report two cases. The first case concerns a 23-year old woman (A) with a mixed germ cell tumor of the right ovary [dysgerminoma (75%), yolk sac tumor (20%), and a mature teratoma (5%)], and the second case concerns a 71-year old woman (B) with a bilateral non-differentiated and necrotic granulosa cell tumor of both ovaries. The staging system was used according to both the classifications: International Federation of Gynaecology and Obstetrics 1987 for ovarian cancer and TNM code 2009. RESULTS: The immunostaining establishes the malignancy and the immunochemistry contributes to confirm effectively the right diagnosis (Tables 2 and 3). CONCLUSION: An immunohistochemical analysis is mandatory for the choice of chemotherapy to obtain a better response of the disease and improve the survival prognosis. The efficiency of the chemotherapy authorizes a conservative surgery including a unilateral salpingo-oophorectomy preserving fertility (A). Concerning the non-dysgerminoma tumor (B), and after a surgical staging and debulking, chemotherapy was recommended. The type of tumor and its histological feature conditioned the choice of treatment. The benefit of the immunohistological analysis in this case allowed the right adjuvant treatment.

Genetic abnormalities detected by comparative genomic hybridization in a human endometriosis-derived cell line.

Comparative genomic hybridization (CGH) was used in parallel with fluorescence in-situ hybridization (FISH) and conventional karyotyping to perform a genome-wide survey of DNA gains and losses in the endometriosis-derived permanent cell line, FbEM-1. The cytogenetic analysis showed a complex karyotype with numerical changes and multiple chromosome aberrations, including the der(1) complement marker exhibiting a large homogenous staining region (HSR). The chromosomal rearrangement interpreted as der(5) t(5;6)(q34;p11) was found in the majority of the metaphases indicating a clonal abnormality. Repeated CGH experiments demonstrated over-representation of chromosomes 1, 2, 3, 5, 6p, 7, 16, 17q, 20, 21q and 22q, while chromosomes 6q, 9, 11p, 12, 13q, 18 and X were under-represented. Using DNA from the original endometriotic tissues, including a peritoneal implant and ovarian endometrioma, CGH analysis revealed loss of DNA copy number on 1p, 22q and chromosome X, while gain was found on chromosomal arms 6p and 17q. FISH analysis confirmed that the gain at 17q includes amplification of the proto-oncogene HER-2/neu in 16% of the FbEM-1 nuclei and in 12% of cells from the primary ovarian endometrioma tissue. These findings demonstrate that FbEM-1 cells share certain molecular cytogenetic features with the original tissue and suggest that chromosomal instability is important in the development of endometriosis.

Cellular and genetic constitution of human endometriosis tissues.

For many years, endometriosis has been an enigmatic and confusing disorder, but there have been recent contributions to the subject, provided by modern techniques in cellular and molecular biology, regarding the cell lineage involved, the stage of differentiation, and genomic features. This review deals mainly with the cellular, cytochemical, cytogenetic, and molecular cytogenetic features of primary endometriotic lesions and cultured endometriotic cells. The FbEM-1 cell line, taken as an in vitro model, showed cell proliferation and differentiation features suggesting an immature endometriosis-related cell lineage. Chromosomal analysis of these cells demonstrate a complex karyotype including a rearrangement interpreted as der(5) t(5q34;6p11) indicating a clonal cell proliferation. Data of recurrent DNA sequence copy number alterations detected by the comparative genomic hybridization in a series of primary endometriotic lesions also are described. Predominant recurrent anomalies were found on chromosome 1p and 22q in 50% of the studied samples. Additional losses were seen on chromosomes 5p(33%), 6q(27%), 7p(22%), 9q(22%), and 1q(22%), as well as on 17q segments in one case. Gain of DNA sequences was seen on chromosomes 6q, 7q, and 17q. The potential role of the genetic changes identified are discussed in relation to the putative oncogenes and/or tumor suppressor genes possibly involved in development of endometriosis.

Detection of DNA copy number changes in human endometriosis by comparative genomic hybridization.

Endometriosis is characterized by infertility and pelvic pain in 10-15% of women of reproductive age. The genetic events involved in endometriotic cell expansion remain in large part unknown. To identify genomic changes involved in development of this disease, we examined a panel of 18 selected endometriotic tissues by comparative genomic hybridization (CGH), a molecular cytogenetic method that allows screening of the entire genome for chromosomal gains and/or losses. The study was performed on native, nonamplified DNA extracted from manually dissected endometriotic lesions. Recurrent copy number losses on several chromosomes were detected in 15 of 18 cases. Loss of chromosome 1p and 22q were detected in 50% of the cases. Additional common losses occurred on chromosomes 5p (33%), 6q (27%), 7p(22%), 9q (22%), 16 (22%) as well as on 17q in one case. Gain of DNA sequences were seen at 6q, 7q and 17q in three cases. To validate the CGH data, selective dual-color FISH was performed using probes for the deleted regions on chromosomes 1, 7 and 22 in parallel with the corresponding centromeric probes. Cases showing deletion by CGH all had two signals at 1p36, 7p22.1 and 22q12 in less than 30% of the nuclei in comparison to the double centromeric labels found in more than 85% of the cells. These findings indicate that genes localized to previously undescribed chromosomal regions play a role in development and progression of endometriosis.

Human endometriosis-derived permanent cell line (FbEM-1): establishment and characterization.

A human epithelial-like cell line derived from peritoneal implants from a patient with gonadotrophin-releasing hormone (GnRH) agonist-resistant endometriosis graded as stage IVd according to the American Fertility Society classification was established in vitro. This cell line, designated FbEM-1, exhibited an epithelial-like morphology, grew in suspension and was immunoreactive for cytokeratins 8, 18, 19, vimentin and human leukocyte class I antigens. The cultured cells were negative for various haematopoietic cell markers, including the lymphoid cell antigens CD3, CD20 and CD45, von Willebrandt factor, carcinoembryonic antigen and the carcinoma antigen-125 (CA-125). In addition, the FbEM-1 cells were found to be moderately positive for periodic acid Schiff's (PAS) solution but were negative for alpha-naphthyl acetate esterase, peroxidase and chloroacetate esterase activities. Using specific antibodies against the progesterone, androgen and oestrogen receptors, approximately 40% and 5-10% of the cells immunostained for progesterone and androgen receptors respectively, while oestrogen receptors were not detected. On cytogenetic analysis using R-banding, these cells showed numerous chromosomal aberrations, including loss of one chromosome X, 4q+, 5q+, trisomy 7,8 and 10 and tetrasomy of chromosomes 17, 18, 19 and 20. These data show that the continuously growing FbEM-1 cell line established from endometriotic implants may be useful in achieving better understanding of the histogenesis of endometriosis.

[Treatment of genital prolapse. Long term results]. / Traitement des prolapsus génitaux. Résultats à long terme.

From 1975 to 1984 case histories of 237 women operated on for major genital prolapse were looked over. 142 formed the subject of prolonged observation of 4 years and more. 63 over ten years. Prévention of static disorders and tissue atrophy has shown itself to be very useful. The procedure for doing this surgical treatment has been dictated by the clinical, urodynamic and per-operative findings. Vaginal surgery treatment was selected for minor uterine prolapse and for very old patients. Most of them had an operation either through abdominal duct or, more often, mixed abdomino perineal duct. The uterine cervix replacement was realized through presacral cervicopexy, by means of non resolving prothesis. In that manner, an anatomical repair can be achieved. We report the excellent long dated results of this method. Posterior perineorraphy remains a high grad process. His result depends upon the quality of perineal muscles. More difficult is the vesical ptosis and urinary stress incontinence treatment, carried, at one and the same time, through intervesico-vaginal prothesis and/or retropublic pexy. Long dated failures depend usually more on the sphincteral insufficiency than on the recurrence of the cervico-vesical ptosis. Perineal and vesico-sphincteral re-education on one hand, substitutive hormonotherapy on the other hand, add a "plus" essential to the surgical repair. Sphincteral bladder insufficiency remains and ill controlled handicap. These desorders are more the consequence of constitutional fragility of connective tissue rather than obstetrical traumatism.

[Laparoscopic salpingostomies: analysis of results]. / Salpingostomies percoelioscopiques: analyse des résultats.

One hundred and twenty three infertile women were treated by laparoscopic salpingostomy. The intra-uterine pregnancy rate is 30.4%. The mucosal status seems to be the principal prognostic factor.

Laparoscopic salpingostomy: fertility results according to the tubal mucosal appearance.

Prognostic factors for fertility outcome following laparoscopic salpingostomy were evaluated. We studied all distal tuboplasties performed between May 1986 and June 1991. Ninety infertile women were treated. Tuboplasty was carried out bilaterally except when one tube was absent or when bifocal lesions were present. Salpingostomy was performed using either scissors and thermocoagulation for eversion, or the CO2 laser. Cumulative pregnancy rates were evaluated by life-table analysis, according to the tubal classification and the mucosal status. The 18 months estimated cumulative pregnancy rate with normal delivery was 28.7%. Pregnancy rates were significantly higher in patients classified in grades I and II versus grade III and IV (severely damaged tubes) according to the distal tubal scoring system, and in patients with normal or lightly atrophic mucosa versus alveolar or absent mucosa. Operative laparoscopy is effective for treatment of hydrosalpinges. Fertility outcome is related to the tubal damage. Our results demonstrate that the prognosis value of the mucosal status seems to be as predictive as the distal tubal scoring system.

[Hernias of the groin. A new complication of celioscopy]. / Les hernies de l'aine. Nouvelle complication de la coelioscopie.

Crural hernia is acquired and mainly affects women. We report a case of hernia discovered after two laparoscopic operations. There was no hernia or risk factor for abdominal wall hernia before the operations. We consider that this hernia is the consequence of repeated abdominal distensions over a short period of time. We have not found this complication in the literature.

Terminal tuboplasties by laparoscopy: 65 consecutive cases.

A series of 65 consecutive laparoscopic distal tuboplasties, performed from May 1986 to May 1988 is reported. Thirty-one were fimbrioplasties and 34 were neosalpingostomies. Outcome was evaluated at 18 months postoperatively. Twenty-two patients obtained pregnancies (33.8%), of which 18 were intrauterine (27.7%). The intrauterine pregnancy rate was 25.8% after fimbrioplasty and 29.4% after neosalpingostomy. These results are comparable with those obtained after microsurgery. Progress in operative laparoscopy may be attributed to the development of an appropriate atraumatic instrumentation and the CO2 laser. The major advantage of laparoscopic techniques is their availability at the time of diagnostic laparoscopy. Immediate opening of hydrosalpinges allows for precise evaluation of the tubal mucosa, thereby establishing prognosis. In cases with a severely altered mucosa, in vitro fertilization may be considered immediately. When the mucosa is satisfactory, laparoscopic fimbrioplasty or neosalpingostomy may be performed. Within 1 year after one of these procedures, a pregnancy is generally achieved in 1 of 3 patients.

[Serous tumors of the ovary with limited malignancy. Current analysis of a review of the international literature apropos of a case]. / Les tumeurs séreuses de l'ovaire à malignité limite. Mise au point à partir d'une revue de la littérature internationale à propos d'un cas.

Serous ovarian tumours on malignancy borderline represent 2 to 5% of the epithelial ovarian tumours. They differ from malignant tumours by two particularities, namely: precise histological characteristics, the main one being the absence of stroma invasion, a favourable prognosis. The diagnosis rests on conventional histology in spite of the value of histo-immunoclinical markers or tumoral markers. The treatment is surgical, based on hysterectomy with bilateral adnexectomy, even if a conservative attitude may be considered for the young woman who wishes a pregnancy. Prolonged post-operative surveillance is very important because of possible relapses, whose detection seems to be facilitated by antigen CA 125 assay.

Reproductive outcome after laparoscopic salpingectomy for tubal pregnancy.

Since 1983, we have performed laparoscopic salpingectomy as a routine procedure for ectopic pregnancy (EP) in cases where conservative management is impossible or contraindicated. The main indications are a ruptured tubal gestation, a pathological tube, a history of tuboplasty, and an ipsilateral recurrence. This technique is simple, quick, and safe. Reproductive outcome after laparoscopic total salpingectomy for EP was evaluated in 125 cases between January 1983 and December 1987. The pregnancy rate was 33.6%. In our population, there was a high proportion of patients with a pathological or absent contralateral tube (74.4%). In patients with a normal contralateral tube (32 cases), the live birth rate (46.9%) was greater but not significantly than in patients (39 cases) with a patent but pathological tube (25.6%). In vitro fertilization (IVF) was performed in 59 patients; clinical pregnancy was obtained in 40.7% of cases. These encouraging results lead us rapidly to consider IVF in patients with a pathological contralateral tube.

[A uterine cleft with a digestive intra-uterine adhesion detected during a cesarean section at term]. / Brèche utérine avec adhérence digestive intra-utérine découverte lors d'une césarienne à terme.

A gap in the wall of the uterus that was discovered by chance during a Caesarean operation carried out at term for a twin pregnancy is reported. This gap was accompanied by adhesion of the digestive tract within the uterus. After the adhesions had been cut away the gap was sutured. The reason for this pathological condition was suction evacuation at termination of pregnancy. We could find no reference in the literature to the combination of such a gap with a pregnancy that continued normally.

[Value and advantages of laparoscopic surgery in the treatment of ectopic pregnancies]. / Intérêt et avantages de la coeliochirurgie dans le traitement des grossesses extra-utérines.

Laparoscopic treatment of ectopic pregnancies (EP) has been performed for several years. From 1st January 1987 to 14th February 1989, 63 women with an EP were operated in our hospital by surgeons trained in laparoscopic surgery (LS). The decision to perform laparotomy was taken either in the presence of laparoscopic contraindications (n = 2), or after diagnostic laparoscopy in the presence of LS contraindications (n = 13). LS was performed 48 times (76.20%) and laparotomy was performed 15 times (23.80%). The women were classified in two groups: laparoscopic surgery (LS) and laparotomy (L). The mean ages were 30.29 and 31.40 years and mean amenorrhea was 6.48 and 6.83 weeks. The EP was ruptured 11 times in the L group (73.33%) and 4 times in the LS group (8.33%). Hemoperitoneum was more frequent in the L group (80.00%) than in the LS group (52.08%). Treatment more often consisted of salpingectomy with laparotomy (86.66%) than with LS (18.75%). Laparoscopic treatment had to be abandoned only once because of persistent bleeding. The mean operation time and hospital stay were shorter in the case of laparoscopic treatment with respectively 63.14 minutes and 4.14 days for LS versus 86.92 minutes and 7.13 days for laparotomy. There were no deaths in either group. This study shows that LS can be used in 3/4 of cases of EP and that treatment significantly shortens the operation time and the hospital stay.

[Tuboperitoneal infertility and operative celioscopy (endometriosis excluded)]. / Infertilité tubo-peritonéale et coelioscopie opératoire (endométriose exclue).

The great progress made in surgical celioscopy now allows most surgery for the repair of the adnexa to be performed through such an approach. The exeresis of adhesions with scissors is the safest, fastest and least traumatic technique. For salpingostomy, the eversion of the cuff is maintained by a defocused CO2 laser shot on the distal tubal serosa, or more simply, by the contact of the serosa with the bipolar pliers or with the tip of the thermocoagulation device. The results of the lysis of adhesions are satisfactory, with 53% intrauterine pregnancies in our 49-patient series. The results of distal plasty, with 27.7% intrauterine pregnancies in our 65-case series, they are quite comparable to those of microsurgical laparotomy. These results, along with the advantages of surgical celioscopy, caused us to give up microsurgical laparotomy for the treatment of operable adhesions and distal tubal lesions, even more so as in vitro fertilization must be contemplated at once for severe lesions.

[Subcutaneous mastectomy. Indications and surgical technics]. / Mammectomie sous-cutanée. Indications et techniques chirurgicales.

After having specified basic anatomy notions (excision line, vascularization, innervation), technics of under cutaneous mammectomy are presented with their alternatives and their difficulties. The opportunity and methods of the prosthetic restoration are debated. Present indications of the under cutaneous mammectomy are related in detail in the malignant and preneoplastic pathology and under other circumstances.

[Ovarian remnant syndrome. Apropos of 4 cases]. / Le syndrome des restes ovariens. A propos de 4 cas.

Four observations of "residual ovarian syndrome" are presented. This syndrome is to be discriminated from the one of "the remaining ovary". These observations are discussed and compared with literature data. After bilateral ovariectomy--or adnexectomy--generally difficult, appear with a variable reaction time, different unrelated or coupled symptoms: signs of renewal of ovarian hormonal activity after a phase of surgical menopause, pelvic pains, dyspareunia, et cetera.... Clinical, biology, echography and even tomodensitometry lead to the diagnosis. The treatment can be: the return of surgery, the pelvic irradiation, antigonadotropic progestogens or abstention.

[Dermoid cyst of the fallopian tube. Apropos of a case]. / Kyste dermoïde de la trompe. A propos d'un cas.

Authors on the subject of a case of fallopian tube dermoid cyst, lay an emphasis on the rarity of this pathology, its clinical polymorphism. With an unknown pathology, the treatment remains only surgical.