[Giant condyloma acuminatum in pregnancy]. / La tumeur de Buschke Lowenstein chez la femme enceinte.

Buschke Lownestein's tumour is a giant acuminate condyloma characterised by its degenerative potential, its invasive nature and its recurrence after treatment. It is a rare condition, transmitted mainly by sexual transmission and induced by to the human papillomavirus (HPV). The discussion will be illustrated by a clinical case The treatment is still under discussion but surgery seems to be the best option. Management during pregnancy is more complex since it must take into account the mother and her fetus. The delivery route is still debated. The post-treatment evolution was satisfactory and without recurrence until the delivery which, due to the antecedent of 3 caesarean sections, was carried out by cesarean section. HPV vaccination, sex education and early treatment of condyloma lesions should prevent and in any case improve the prognosis of this disease.

Obstetric outcomes associated with induction of labour after caesarean section.

PURPOSE: To evaluate the efficiency and safety of inducing labour with oxytocin in women with a single prior Caesarean section, with particular focus on the Bishop score. METHODS: Between January 1, 2013 and March 31, 2017, we included all women with a singleton full-term pregnancy and single prior Caesarean section in this monocentric retrospective observational study. Women for whom vaginal delivery was not recommended and those who went into spontaneous labour were excluded. The choice between induction of labour and caesarean section was made by the obstetrician and the patient, taking into account both the patient's personal medical history and the clinical observations on admission to hospital. The primary outcome was the rate of vaginal delivery. RESULTS: Out of 966 women with no contraindication to trial of labour after previous caesarean delivery (TOLAC), 248 were induced, with a vaginal delivery rate of 58.5% (95% CI [52.06; 64.67]). This rate was 81.7% (67/82) among women with Bishop ≥6 and 47% (78/166) if Bishop was <6. Eight cases of uterine rupture were reported in the induction of labour group. Regarding maternal morbidity, this was the main difference between the caesarean section and the induction of labour groups (p=0.049). Neonatal morbidity was low in both groups. CONCLUSIONS: The rate of vaginal delivery after induction of labour with oxytocin infusion was satisfactory. Nevertheless, maternal morbidity and especially the risk of uterine rupture were not minor. It is thus essential before inducing labour to inform the woman about the rate of success of TOLAC and the risks of uterine rupture.

Limiting factors for development of ambulatory breast surgery in the French hospital network.

INTRODUCTION: Ambulatory breast surgery is not well developed in France. This is especially true for oncologic procedures, MATERIALS AND METHODS: Between January 2005 and June 2006, we performed a retrospective evaluation of the factors thought to limit the development of this type of hospitalization. RESULTS: The principal limiting factors were distance restrictions (respect of the 100 km perimeter), the complexity of patient management for small breast tumors (several practitioners involved) and last, the non-motivating reimbursement policy. CONCLUSION: By changing to the Anglo-American ("one day surgery", i.e. hospital stay less than 24 hours) or hybrid system (less than 12 hours+1 day surgery), ambulatory surgery could easily be offered to patients excluded by the current system (ambulatory department open less than 12 hours).

[Cervical pathology: significance and therapeutic impact of margin status]. / La notion de marge d'exérèse dans le contexte de la pathologie du col utérin : définitions et impact thérapeutique.

Margin status in cervical pathology is one of most important predictive factor of recurrent disease. Even if management of surgical biopsy is standardized, quality of surgical procedure is fundamental. Frozen section can be realise in order to complete surgical procedure if margins are involved. Extemporaneous exam of endocervical margin during conservative surgery and vaginal cuff during radical surgery is a precious information for surgeon. Endocervical status for conization, parametrial and vaginal margins have been reported to be a factor predictive of residual disease. During radical trachelectomy, margins involvment of one of these three topographic zone is an important predictive factor of recurrent disease and can be an obstacle to preserve fertility.

[Uterine abnormalities in non menopausal women who received tamoxifen for breast cancer adjuvant therapy]. / Anomalies utérines chez la femme non ménopausée sous tamoxifène en traitement adjuvant du cancer du sein.

OBJECTIVE: To elaborate a strategy of endometrial follow-up for premenopausal women treated with Tamoxifen as adjuvant hormonal treatment of breast cancer. PATIENTS AND METHODS: Retrospective study of 152 premenopausal patients treated with Tamoxifen in Nantes Comprehensive Cancer Center for a breast cancer from January 2003 to December 2005. Vaginal sonography was used in the follow-up of 70 of them. RESULTS: Endometrial hypertrophy was found in 26 patients. Sonohysterography and hysteroscopy allowed to find 11 polyps and three hyperplasias in the 19 women who were investigated. In our study, endometrial pathology was found in 20% of premenopausal women treated with Tamoxifen (polyps or hyperplasia). Uterine bleeding was found in half patient of this group. DISCUSSION AND CONCLUSION: Vaginal sonography monitoring could be proposed to premenopausal women treated with Tamoxifen among whom endometrial pathology is usual.

[Ductal carcinoma in situ of the breast with microinvasion. Role of sentinel lymph node biopsy]. / Cancer canalaire in situ du sein avec micro-invasion. Place du ganglion sentinelle.

OBJECTIVES: To investigate the role of sentinel lymph node biopsy for microinvasive ductal carcinoma in situ of the breast. PATIENTS AND METHODS: From January 2001 to January 2006, lymphatic mapping was performed using radiocolloid and/or blue dye technique. Full axillary lymph node dissection was accomplished systematically in 10 instances at the beginning of the study, and furthermore when the sentinel node was involved (macrometastatic or micrometastatic disease). RESULTS: Identification rate was 98% (40/41), the unsuccessful procedure occurred after incisional biopsy for diagnosis. The number of sentinel nodes removed was 2 in average (1-5). Sentinel node involvement was found in 10% of cases (4/40): 1 sentinel node macrometastasis pN1, 2 sentinel node micrometastases determined by hematoxylin and eosin staining pN1 (mi), 1 sentinel node micrometastasis detected only by immunohistochemical staining pN0 (mi). DISCUSSION AND CONCLUSION: Sentinel lymph node sampling should not be currently applied for management of every ductal carcinoma in situ of the breast but a selective utilization is proposed in documented high risk subset of patients according to clinical, mammographic, and histologic features obtained by percutaneous biopsies. Ductal carcinoma in situ (DCIS) with proved or suspected microinvasion could be scheduled for sentinel node procedure a fortiori in cases undergoing mastectomy because of extensive DCIS before the occurrence of disturbances of lymphatic drainage induced by surgical breast dissection.

[What surgical procedure for immediate breast reconstruction after preoperative radiotherapy and chemotherapy?]. / Quel type de reconstruction mammaire immédiate après radiothérapie externe et chimiothérapie pré-opératoire?

OBJECTIVE: To evaluate retrospectively the morbidity of four different surgical procedures for immediate breast reconstruction (IBR) in the setting of neoadjuvant chemotherapy and radiotherapy, and to determine which procedure is best adapted to these circumstances. PATIENTS AND METHODS: Immediate breast reconstruction was undertaken in 101 patients who had undergone neoadjuvant chemotherapy and radiotherapy for invasive breast carcinoma. IBR was accomplished by transverse rectus abdominis musculocutaneous flap (TRAM) in 38 patients, by latissimus dorsi musculocutaneous flap with prosthesis (LDMP) in 32, by autologous latissimus dorsi musculocutaneous flap (ALDM) in 15, and by simple prosthetic implant in 26. RESULTS: The complication rates for TRAM. LDMP, ALDM and prosthesis were respectively 50%, 37.5%, 85%, and 62%. The need for additional surgical procedure(s) was respectively 29%, 15%, 6%, and 56%. The complication rate was significantly worse (p=0.013) for ALDM (RR=1.73, IC95%=1.12-2.69), and the need for surgical revision was worst (p=0.00087).for simple prosthetic implant (RR=1.99, IC95%=1.11-3.59). CONCLUSION: IBR using musculocutaneous flap is superior to the use of prosthetic implant in patients having undergone neoadjuvant chemotherapy and radiotherapy.

[Polycythemia and fibromyoma. Case report]. / Polyglobulie et fibrome utérin. A propos d'un cas.

Leiomyoma of the uterus is a frequent benign tumor of non menopausal women. Among possible complications, polycythemia is rare and often unrecognised. We report a very demonstrative case, that of a 52-year-old woman, who presented initially an episode of metrorrhagia. The difficulty of diagnosis and the treatment are detailed. The different physiopathological hypotheses are discussed in order to ameliorate our knowledge about this association between fibromyoma and polycythemia, and to optimise therapeutic management.

[Is there still a place for extemporaneous exam in breast cancer?]. / Existe-t-il encore une place pour l'examen extemporané dans le cancer du sein?

OBJECTIVE: The rise of preoperative diagnosis thanks to new methods of micro and macrobiopsy and the development of sentinel lymph node have dramatically modified the surgical management of patients with breast tumor. The purpose of this study is to know if extemporaneous exams still have a place in the management of breast cancer. PATIENTS AND METHODS: Retrospective study which compares the qualitiative evolution of frozen sections in breast tumor at Jean-Perrin center before the practice of percutaneous strereotaxic biopsy and after the training of sentinel lymph node operative biopsy. RESULTS: The results were in favour of a different distribution of anatomocytopathological activity with a decrease of frozen section in breast tumor and an increase of cytological imprints on sentinel nodes. DISCUSSION AND CONCLUSION: The interest of histologic preoperative diagnosis and the failure of consensus in the sentinel lymph node just leave a restrictive position to frozen section in breast cancer.

[Endometrial cancers arising in polyps associated with tamoxifen use]. / Dégénérescence maligne de polypes endométriaux sous tamoxifène.

OBJECTIVES: To review and describe the anatomoclinical cases of the endometrial cancers arising on polyps during a hormonotherapy by tamoxifen for breast cancer. PATIENTS AND METHODS: In the surgical inventory 1990-2002 of the benign or malignant uterine lesions investigated by hysteroscopy with dilatation & curettage (D&C) and/or hysterectomy, 108 single or multiple endometrial polyps were encountered and histologically analyzed. RESULTS: A malignant transformation of polyp was found in 5 instances, meaning a rate of 4.6% i.e. 5/108: 4 cases of adenocarcinoma, 1 case of sarcoma. DISCUSSION AND CONCLUSION: The existence of endometrial polyps - symptomatic or not - does not seem compatible with the prolonged use of tamoxifen treatment owing the estrogen agonist potential effects of tamoxifen and its well-known hyperplastic and carcinogenic properties for the endometrium. The increased risk of endometrial cancer developing in polyps in this iatrogenic context is estimated between 2.5% and 10% in the literature.