[Interposition of a synthetic mesh by vaginal approach in the cure of genital prolapse]. / L'interposition d'un treillis synthétique dans la cure par voie vaginale des prolapsus génitaux.

There are two goals for treatment if vaginal prolapse, restauration of normal function and anatomy and prevention of recurrence. Most operations described for replacement and maintenance of prolapsed organs in the pelvic cavity do not treat the cause of the prolapse which is diastasis of levator muscles and, in most cases, failure of the pelvic fascia. By analogy with the treatment of parietal hernias, the concept of a synthetic graft to reinforce failing fascias and restauration of normal anatomy has been proposed. From June 1994 through March 1999, 46 patients were treated for genital prolapse by a vaginal approach with positioning of a polyester mesh sutured to the vaginal angles. No major complication was observed. One mesh exposure occurred 4 months after treatment of a cystocele with vaginal hysterectomy and was treated by partial resection with good outcome. With a 5-year follow-up (median 26 months), all patients are totally satisfied. No recurrence of prolapse was observed. Sexual function was preserved without dyspareunia. This study demonstrates the feasability and efficacy of using a synthetic graft in the cure via a vaginal approach of genital prolapse. Complementary studies are necessary to evaluate the indications for which the procedure can be proposed and how it should be integrated in to schemes with other procedures.

Familial cluster of ovarian small cell carcinoma: a new mendelian entity?

We report a pedigree in which three sisters had a particular type of ovarian cancer, small cell carcinoma of the hypercalcaemic type. This rare type of ovarian carcinoma is now well characterised by clinical and pathological findings and is well distinguished from other ovarian epithelial tumours and ovarian germ cell tumours. The occurrence of this rare type of cancer in several members of the same family and the existence of four other similar published observations raises the question of the genetic determination of this kind of tumour.

[Brachytherapy of cancer of the penis. Analysis of a series of 53 cases]. / Curiethérapie des cancers de la verge. Analyse d'une série de 53 cas.

From 1970 through 1984, 53 patients with squamous cell carcinoma of the penis have been treated by interstitial irradiation with iridium 192 wires; in this group 33 patients have been followed for at least ten years. There were 7 T1, 31 T2, 15 T3 and 37 N0, 7N1, 6 N2, 3 N3 (WHO classification, 1979). Forty eight patients were treated by interstitial radiotherapy alone, after previous circumcision for 35 of them, and five by an association of external and interstitial radiotherapy. Eleven patients presented a local recurrence; all but one were controlled by penile amputation. Fifteen patients developed severe complications (necrosis, urethral stenoses treated by surgery) and ten of them underwent a secondary total or partial penile amputation. Complications are strongly correlated with the irradiated area and the dose (over 65 grays). Recurrences and complications may develop very late after the treatment, beyond ten years. They required 12 partial and 10 total amputations. Interstitial radiotherapy is the first line treatment for carcinoma of the penis and it is well accepted by the patients. However, to keep a reasonable rate of complications and recurrences we limit the indications of interstitial radiotherapy to the small lesions (T1-T2) and we suggest to decrease the dose under 65 grays. To avoid some local failures we treat now the whole glans.

Adjuvant trial for stage II receptor-positive breast cancer: CMF vs. CMF + tamoxifen in a single centre.

The purpose of a randomized trial achieved in a single centre (Fondation Bergonié, Bordeaux, France) was to compare chemotherapy alone (intravenous CMF) versus chemotherapy and hormonotherapy (CMF plus tamoxifen-30 mg per day during 2 years), for patients with stage II breast carcinoma and positive values of estrogen and/or progesterone receptor (EPR) (greater than 10 and greater than 15 fmoles mg protein-1 respectively). Three hundred and thirty four women treated by surgery +/- radiotherapy are included in this trial from 06.01.81 to 12.31.84. No patient is lost for follow-up. Eight are excluded. Three hundred and twenty six patients are evaluable with a 38 month median follow-up. For EPR assay, the dextran charcoal micromethod was used in the same centre. The two groups are identical as far as age, hormonal status, TNM, EPR values, and histological features are concerned. Analysis of results shows a significant improvement of relapse free survival (p = 0.018) and also overall survival (p = 0.04) for the CMF+ tamoxifen group.

Clinical study of an LH-RH agonist (ICI 118.630, Zoladex) in the treatment of prostatic cancer.

Eighty patients with prostatic cancer have been treated with an LH-RH analogue (Zoladex). Ten had no metastasis, and hormone therapy was used as an induction treatment before curative radiotherapy. The others had metastatic disease and, in some cases, had already received some form of endocrine therapy. Patients received a monthly injection of Zoladex (3.6 mg). No progressive disease was noted among patients with nonmetastatic tumors; of the patients with metastases, those who were previously untreated had a higher response rate (14.8% complete response) and longer progression-free and overall survival. Toxicity was mild in spite of two cases of disease flare.

[Conservative axillary curettage in the treatment of operable breast cancers]. / Le curage axillaire conservateur dans le traitement des cancers du sein opérables.

Functional motor and sensory sequelae of conservative or non-conservative treatment of breast cancer are due essentially to axillary curettage, during which the nerve branches crossing the axillary pyramid are often sectioned. Analysis of axillary glands is now fundamental for determination of prognosis and adjuvant treatment required. The present report demonstrates that knowledge of the glandular state can be obtained, while limiting functional sequelae, by careful dissection of axilla avoiding all nervous elements (motor nerves of latissimus dorsi, serratus anterior and pectorals, perforating intercostal sensory nerves) and the must important vascular structures (inferior scapula pedicle and pedicle of pectoral muscles.

[Approach to therapeutic risk by study of operative mortality. From 102 postoperative deaths between 1975 and 1984 at the Fondation Bergonié]. / Approche du risque thérapeutique par l'étude de la mortalité opératoire. A partir de 102 décès post-opératoires survenus en 10 ans (1975-1984) à la Fondation Bergonié.

A retrospective analysis of operative mortality in the cancer surgery department of the Fondation Bergonié between 1975 and 1984 allowed priority objectives to be defined requiring maximum efforts of the treating team. During this decade, 18,582 patients underwent surgery; 15,794 "first hand" operations were for cases not previously treated. Amongst the latter, 102 died within 90 days of surgery, 45 due to multifocal or apparently isolated pulmonary infection and 57 without any known infectious context. Separating patients into two groups: periods 1975-1979 and 1980-1984, demonstrated a notable decrease in postoperative mortality from 68 to 34. This improvement was due mainly to a reduction in deaths from infection (from 37 to 8 patients in the period 1980-1984). This marked improvement was probably the result of various combined causes: Mastery of parenteral nutrition enabling patients to be operated upon in better condition, or to tolerate possible complications better; Use of routine antibiotic therapy before surgery to digestive tube or ORL regions. These encouraging result suggest the need for enlargement of indications for routine prophylactic antibiotic therapy.

[Palliative chemotherapy of endometrial cancer. Value of combinations with doxorubicin and cisplatin]. / Chimiothérapie palliative des cancers de l'endomètre. Intérêt d'associations avec doxorubicine et cisplatine.

The study of a series of 21 consecutive cases of adenocarcinomas of the endometrium requiring chemotherapy, has permitted to demonstrate the superior efficacy of an association of doxorubicin and cisplastin as compared to other plans containing only anthracyclin (45% of partial and complete remissions versus 20%); this difference, however, is not statistically significant. Intolerance reactions were similar in both groups. Confirming recent data from the literature, the results conclude in favor of: the determinant contribution of cisplastin to chemotherapy, the need of a strict selection of the patients intended for chemotherapy, the usefulness of induction chemotherapy trials, prior to pelvic radiotherapy in locally advanced forms, to improve their distant prognosis.

[Immediate repair of urethroperineal fistulas after abdominoperineal amputation by means of a cutaneo-muscular flap of the gluteus maximus. Apropos of 2 successfully treated cases]. / Réparation immédiate des fistules uréthropérinéales après amputation abdominopérinéale à l'aide d'un lambeau cutanéo-musculaire du grand fessier. A propos de 2 cas traités avec succès.

Although a rare complication, the development of a urethro-perineal urinary fistula immediately after abdomino-perineal amputation is a difficult problem to solve. The fragility of the membranous urethra immediately in contact with the exenterated pelvic cavity which takes several weeks to fill in makes any attempt at isolated direct suture very hazardous. Secondary repair is also frequently difficult and the "functional prognosis is far from being always favourable". The major handicap resulting from the perpetuation of this type of fistula has led us to propose an attempt at immediate repair as soon as it is diagnosed with filling of the pelvi-perineal cavity by a cutaneo-muscular flap taken from gluteus maximus. In the two cases in which this treatment was performed, the fistula was cured and a good quality functional result was obtained.

[Role of chemotherapy in the treatment of soft tissue sarcoma in adults]. / Place de la chimiothérapie dans le traitement des sarcomes des tissus mous de l'adulte.

Soft tissue sarcomas of adults represent an heterogeneous group of rare malignant tumors, for which clinical and histopathological prognostic factors are now well defined. The GTNM classification recommended by the UICC is effectively predictive for the metastatic potential of these diseases. Although chemotherapy still have limits in advanced sarcomas, the efficacy level reached allows to consider its use with a curative intend, in multidisciplinary therapeutic program. A critical analysis of the studies already published shows that adjuvant chemotherapy can reduce the distant metastases rate in patients presenting an operable primary tumor. Furthermore, the preliminary results of a study indicate that neoadjuvant (induction) chemotherapy may be of value for primarily inoperable patients. All these encouraging results remain to be confirmed by further studies with a long-term follow up of the patients.

[Spontaneous regression of pulmonary images interpreted as metastases of kidney cancer. Apropos of 2 cases]. / Régression spontanée d'images pulmonaires interprétées comme métastases de cancer du rein. A propos de deux cas.

The authors report two cases of spontaneous regression of pulmonary metastases from hypernephroma; this is an exceptional event that occurs in 0.8% of metastasized renal carcinomas; spontaneous regression in all cancers as a group occurs in 0.0014% of cases. The theories postulated up till now to explain this phenomenon are unconvincing. The authors suggest the possibility of tumorous emboli: this event, that occurs mainly in those carcinomas with a propensity for extension to veins, such as renal carcinoma, choriocarcinoma, hepatoma and liver metastases, does not necessarily give rise to a metastasis. The evidence that leads to advocate nephrectomy in metastasized renal carcinoma are recalled and discussed.

[Diagnostic and therapeutic approach to the extension of kidney cancer to the vena cava]. / Approche diagnostique et thérapeutique de l'extension à la veine cave des cancers du rein.

In the light of their experience with 16 cases seen over 5 years, the authors analyze the diagnostic and therapeutic tools for assessment of the vena cava thrombi that complicate 5 to 10% of renal carcinomas. Cavography still plays a central part in the detection of vena cava lesions. Localization of the upper extremity of the thrombus is needed to decide upon the operative technique and can be achieved by free flow inferior cavography for free floating thrombi; for complete thrombi, the two most informative procedures appear to be echocardiography (to evaluate the right atrium and intrathoracic inferior vena cava) and inferior cavography by the superior route; it seems that computed tomography provides no additional information in the assessment of extensive spread to the inferior vena cava. 14 patients were treated surgically: the surgical approach is dictated by the location of the thrombus and should allow control of the vena cava proximal to the thrombi. Two patients with a thrombus that extended into the right atrium had surgery using extracorporeal circulation; because this method is especially safe, extension of its indications to retrohepatic thrombi may be justified. The absence of operative mortality and comparison of results to those previously reported in the literature confirm the value of surgical treatment of vena cava lesions, especially if there is no lymph node involvement.

[Cancer of the prostate: estrogen therapy]. / Cancer de la prostate: l'estrogénothérapie.

From 1941, estrogens are usually used in the treatment of prostatic carcinoma, wrongly in case of adjuvant hormonotherapy and exceedingly because of cardiovascular toxicity from over dosages. A recall of their mechanism of action and toxicity allows to argue about the palliative treatment and to look to their use for the locally advanced cancers in order to get a tumoral reduction before radiotherapy. A pilot study realised by the authors shows that this hormono-radiotherapic protocol is achievable.

[Prognostic significance of isolated local recurrences in breast cancer following mastectomy and axillary node excision. Apropos of 77 recurrences in 2362 patients]. / Signification pronostique des récidives locorégionales isolées dans les cancers du sein après mastectomie et curage axillaire. A propos de 77 récidives chez 2 362 patientes.

During the years 1958-1984, 2 362 patients presenting with breast carcinoma were treated at the Fondation Bergonié by modified radical mastectomy and followed or not by radiotherapy or adjuvant chemotherapy. A retrospective analysis of this series showed that 77 patients (3.3%) presented an isolated locoregional recurrence as the first sign of treatment failure. A chest wall recurrence alone was noted in 47 patients, while 30 presented an involvement of the lymph nodes, sometimes associated with chest wall disease. The prognosis' factors of isolated locoregional recurrence, studied by multidimensional analysis by Cox's model are by decreasing order the disease free interval and the Scarf and Bloom's histologic grade. The median survival is 29 months after isolated locoregional recurrence and the survival curve is very similar to that of patients with isolated bone metastatic recurrences (median survival of 26 months) and slightly better than the median survival of patients with non osseous metastasis (median survival of 16 months).

[Prostatic osteocondensing metastases and osteomalacia. Value of histomorphometric study. Preliminary results]. / Métastases ostéocondensantes prostatiques et ostéomalacie. Intérêt de l'étude histomorphométrique. Résultats préliminaires.

A clinical, biochemical and histomorphometric study of non-decalcified bone with measurement of calcification rate was carried out in 10 patients with sclerotic bone metastases from prostatic carcinoma. The patients were under oestrogen therapy, and a change of treatment was being considered. The histomorphometric study showed that 3 patients had osteomalacia. These patients differed from the others in that the pain they experienced in bones was stronger, more diffuse and more often permanent. All three had fracture of the femoral neck. They had hypocalcaemia, hypophosphataemia, hypocalciuria and increased serum alkaline phosphatase, but only phosphataemia was significantly lower than in non-osteomalacia patients. Osteomalacia was cured by vitamin D and calcium in one patient. Osteomalacia can only be reliably diagnosed in these patients by histomorphometry. This examination may be proposed to patients with sclerotic bone metastasis of prostatic origin, under hormonal therapy, presenting with diffuse skeletal pain or bone fragility without osteolysis, and with hypocalcaemia or hypophosphataemia.

[Conservative loco-regional treatment of soft tissue sarcoma in adults after induction chemotherapy]. / Traitement loco-régional conservateur des sarcomes des tissus mous chez l'adulte après chimiothérapie d'induction.

Between June, 1979 and December, 1983, 23 adult patients with non-metastatic soft tissue sarcoma were treated with induction chemotherapy since local spread precluded primary conservative surgery. Eighteen patients received a combined cyclophosphamide, vincristine, adriamycin and dacarbazine treatment and 5, a combined adriamycin, cis-platinum and vindesine treatment. Both drug combinations exhibited toxic effects, notably on blood and digestive tract. However, tumoral volume was reduced by 50 p. cent or more in 14/23 patients, including 2 complete remissions; the course of the disease remained unchanged under treatment in only 3 cases. Chemotherapy facilitated surgical excision in 14 patients, and subsequent radiotherapy resulted in complete remission in 13 of these. None of the 13 patients relapsed during a mean follow-up period of 12 months (range: 3 to 48 months). Among the 9 patients who could not be operated upon, 5 benefited from radiotherapy with satisfactory local control, but only one still remains in complete remission. Thus, induction chemotherapy made it possible to achieve local control in two-thirds of patients with locally advanced sarcoma. However, a more prolonged follow-up is necessary to confirm that these results are long-lasting and to determine the effects of chemotherapy, if any, on the metastatic potential of these tumours.

[Prostatic osteocondensing metastases. The value of examining for osteomalacia]. / Métastases ostéocondensantes prostatiques. Intérêt de la recherche d'une ostéomalacie.

Bone pains observed in patients undergoing estrogen therapy, and presenting with osteoblastic metastases from prostatic cancer are usually related to unsuccessful treatment. In some patients, these pains may result from osteomalacia--ie incomplete mineralization of the new bone--because of the drainage of calcium by the osteoblastic metastases. A clinical, biological and histomorphometric study of bone specimens without decalcification was conducted in ten patients with osteoblastic disease secondary to prostatic carcinoma, who were under estrogen therapy, and for whom a change of therapy was contemplated. The study reports three cases of osteomalacia. Their bone pains were more intense, more diffuse and more permanent than those registered by patients without osteomalacia. All three had had previous fractures of the neck of the femur and a low urinary and serum calcium and phosphorus content. The discovery of osteomalacia by histomorphometric study is important because it allows effective, etiological treatment of the bone pains in these patients.