Manifestaciones cutáneas en pacientes hemodializados crónicos: Estudio prospectivo sore 100 casos / Cutaneous manifestations in chronic hemodialysis patients: Study with 100 cases

Las manifestaciones cutáneas, son comunes y diversas en los pacientes con insuficiencia renal crónica (IRC), sobre todo, en aquellos en hemodiálisis (HD). Estas pueden ser anteriores al inicio de la diálisis o podrían ser precipitadas por ella. Materiales y Métodos: estudio observacional, descriptivo, de serie de casos, prospectivo a través del examen de piel realizado por dermatólogos, a 100 pacientes con IRC en HD del Servicio de Nefrología del Hospital Provincial del Centenario de Rosario, Argentina durante el período comprendido entre el 1 de Junio de 2013 hasta el 1 de Junio de 2014. Resultados: en este estudio se incluyeron 100 pacientes con IRC en HD, de los cuales 91 presentaron manifestaciones cutáneas. Discusión: la frecuencia de patologías cutáneas en pacientes con IRC en HD, varía del 50 al 100% y generalmente, se observan más de una manifestación cutánea. Esto coincide con lo hallado en nuestro trabajo, donde de los 100 pacientes: 91 presentaban lesiones y de éstos, la mayoría presentaba 2 o más. Respecto de la edad, el rango es amplio y en nuestro trabajo se observó un predominio en el sexo masculino, al igual que en otros estudios.

Skin manifestations are common and diverse in patients with chronic renal failure (CRF), especially those on hemodialysis (HD). These may be prior to initiation of dialysis or could be precipitated by it. Materials and Methods: observational, descriptive, case series, prospective through the skin examination by dermatologists of 100 patients with CKD on HD in the Nephrology Service of Hospital Provincial del Centenario of Rosario, Argentina during the period June 1, 2013 to June 1, 2014. Results: in this study of 100 patients with CRF in HD, of which 91 had cutaneous manifestations were included. Discussion: the frequency of skin diseases in patients with CRF in HD, varies from 50 to 100% and it is usually seen more than one cutaneous manifestation. This coincides with the findings in our study where from 100 patients, 91 had injuries and of these the majority had 2 or more. Regarding age, the range is wide and our study found a predominance in males, as in other studies.

HPV self-sampling or the Pap-smear: a randomized study among cervical screening nonattenders from lower socioeconomic groups in France.

Today in France, low attendance to cervical screening by Papanicolaou cytology (Pap-smear) is a major contributor to the 3,000 new cervical cancer cases and 1,000 deaths that occur from this disease every year. Nonattenders are mostly from lower socioeconomic groups and testing of self-obtained samples for high-risk Human Papilloma virus (HPV) types has been proposed as a method to increase screening participation in these groups. In 2011, we conducted a randomized study of women aged 35-69 from very low-income populations around Marseille who had not responded to an initial invitation for a free Pap-smear. After randomization, one group received a second invitation for a free Pap-smear and the other group was offered a free self-sampling kit for HPV testing. Participation rates were significantly different between the two groups with only 2.0% of women attending for a Pap-smear while 18.3% of women returned a self-sample for HPV testing (p ≤ 0.001). The detection rate of high-grade lesions (≥CIN2) was 0.2‰ in the Pap-smear group and 1.25‰ in the self-sampling group (p = 0.01). Offering self-sampling increased participation rates while the use of HPV testing increased the detection of cervical lesions (≥CIN2) in comparison to the group of women receiving a second invitation for a Pap-smear. However, low compliance to follow-up in the self-sampling group reduces the effectiveness of this screening approach in nonattenders women and must be carefully managed.

Vaginal self-sampling is an adequate means of screening HR-HPV types in women not participating in regular cervical cancer screening.

In France, about 40% of women aged 25-65 years do not participate in regular screening and thus are at high risk (HR) of cervical cancer. Human papillomavirus (HPV) vaginal self-sampling is a valuable alternative in this population. This study aimed to assess the prevalence of HR and LR (low-risk) HPV infection in 3767 women aged >35 years from mid-socioeconomic backgrounds who carried out HPV vaginal self-sampling at home. HPV vaginal self-sampling was better accepted than the Pap-test in women aged 35-69 years who were previously non-responders to individual invitation. From the 933 self-collected swabs studied (24.7%), 62 were HPV-infected (6.6%), and 73 HPV types were found. HPV 16 was the most frequently found (43.5%), followed by 53 (23.2%), 18 (12.3%), 66 (12.3%), 31 (6.8%), 33 (5.4%) and 58 (2.7%). Ten women (16.2%) were infected by multiple HR-HPV types. Median HPV 16 load was 104.000 copies/10(6) cells and median HPV 18 load was 833 copies/10(6) cells. Six women (9.3%) harboured LR-HPV types. The 12-month follow-up of 43 HR-HPV positive women (69.3%) revealed CIN2-3 lesions in three women (6.9%), all HPV 16 infected, and harbouring an HPV 16 load >5 log(10) copies/10(6) cells. Women harbouring HR-HPV types other than HPV 16/18 were older than women harbouring HPV 16/18 types (55 years vs. 46.9 years, p 0.0008). The high frequency of HR-HPV types in women >50 years deserves further investigation to elucidate the mechanism involved (re-infection or reactivation).

[Standpoint and practice concerning the human Papillomavirus vaccine among French family physicians]. / Opinions et pratiques des médecins généralistes face à la vaccination anti-Papillomavirus.

AIMS: The purpose of this study was to assess the standpoint of family physicians in the Southern French region Provence-Alpes-Cote d'Azur concerning human Papillomavirus vaccination and to evaluate the factors associated with a favorable standpoint. METHODOLOGY: A questionnaire was sent to a random sample of 1,000 family physicians. The survey focused on their profile, their views on vaccination generally and on HPV vaccination, their knowledge of HPV, their standpoint concerning STD prevention and cervical cancer screening. Multivariable linear regression system was used to study the variations associated with a favorable response to HPV vaccination. OUTCOME: Response was 36.6%. The responses were analyzed taking into account gender of the family physicians, location and size of their practice. There was reasonable similarity amongst those questioned. Around 89.6% of family physicians answers were in favor of HPV. The ideal age for vaccination was between 11 and 13 years of age for 34.4% and between 14 and 15 for 53.9%. The family physicians most in favor of vaccination were those involved in screening for STDs, those who did not think that the vaccine would have a negative effect on the image of sexuality and on screening for cervical cancer, and those who were confident about the vaccine safety. CONCLUSION: The study identified the negative elements concerning HPV in order to optimize information strategies among family physicians.

Concomitant intensive chemoradiotherapy induction in non-metastatic inflammatory breast cancer: long-term follow-up.

The aim of this study was to evaluate with a long follow-up the efficacy of concomitant chemoradiotherapy in non-metastatic inflammatory breast cancer (IBC) and to evaluate the breast conservation rate. Between 1990 and 2000, 66 non-metastatic patients with IBC were treated with chemotherapy and concomitant irradiation. The induction chemotherapy consisted of epirubicine, cyclophosphamide and vindesine, in association with split-course bi-fractionated irradiation to a total dose of 65 Gy with concomitant cisplatin and 5-fluorouracil. Maintenance chemotherapy consisted of high-dose methotrexate and six cycles of epirubicine, cyclophosphamide and fluorouracil. Hormonal treatment was given if indicated. Mastectomy was not systemic. Among 65 evaluable patients, 57 (87.6%) achieved a complete clinical response and had a breast conservation. Only six loco regional relapses were noted in six patients with a delay of 20 months and with concomitant metastatic dissemination in four cases. Median disease-free survival (DFS) was 28 months. Median overall survival (OS) was 63 months and median follow-up was 55.5 months. Induction chemotherapy and concomitant irradiation is feasible in patients with IBC, permitting a breast conservation with a high rate of local control with an OS comparable to that of the best recent series.

Severe lower limbs lymphedema following breast carcinoma treatment revealing radiation-induced constrictive pericarditis--a case report.

In patients treated for breast carcinoma, unilateral lymphedema of the upper limb is usual. However, to the authors' knowledge, lower limb lymphedema has never been reported as a complication of breast carcinoma therapy. They report here the first case of a radiation-induced constrictive pericarditis revealed by severe lower limbs lymphedema. A 60-year-old woman was treated for left breast carcinoma with quadrantectomy, axillary lymphadenectomy, and combined radio chemotherapy (60 grays). Three and a half years later she suffered from a diffuse and increasing lower limbs lymphedema, which became huge and disabling. Radiation-induced constrictive pericarditis was evidenced by right cardiac cavities catheterization. A dramatic improvement was rapidly obtained after pericardectomy. Histopathologic analysis of the pericardium did not reveal neoplastic cells. Radiation-induced constrictive pericarditis is usually responsible for lower limbs edema, but lymphedema is exceptional. This case highlights the need to search for a constrictive pericarditis also in the case of lower limbs lymphedema, particularly in a patient treated with mediastinal radiotherapy or combined radio chemotherapy.

Does hormone replacement therapy increase the frequency of breast atypical hyperplasia in postmenopausal women? Results from the Bouches du Rhone district screening campaign.

It is thought that the risk of atypical hyperplasia (AH) increases with age, particularly among postmenopausal women. Three hypotheses were investigated to try to explain this phenomena: use of hormone replacement therapy (HRT), increased breast cancer screening and improvements in radiological quality. Data were collected from the Bouches du Rhône breast cancer screening programme database and from the pathological registry of all women operated on for breast diseases in the district. The AH incidence rate was studied using a Poisson regression analysis. The change in the profile of breast diseases was explored through studying changes in the proportion of AH among benign lesions and malignant diseases. The AH incidence rate significantly increased over time (13.6% per year). The proportion of AH among the benign diseases increased with time and was significantly higher for HRT users (Odds Ratio (OR)=2.05; 95% Confidence Interval (CI): 1.43-2.93). While AH decreased with age among HRT non-users, it increased among users as a proportion of both benign and malignant lesions. The AH incidence rate significantly increased among pre- and postmenopausal women. Our study suggests that this increase is partly explained by the incidental discovery of these lesions by mammography and partly by a real increase of the disease among HRT users.

Chemotherapy and concomitant irradiation in inflammatory breast cancer.

The purpose of this study was to evaluate the efficacy of concurrent chemotherapy and irradiation in inflammatory breast cancer (IBC). Between January 1990 and December 1998, forty-eight non-metastatic patients with clinical or occult IBC were treated with chemotherapy and irradiation. The induction chemotherapy consisted of epirubicin, cyclophosphamide and vindesin, in association with split-course bi-fractionated irradiation to a total dose of 65 Gy with concomitant cisplatin and fluorouracil. Maintenance chemotherapy consisted of high-dose methotrexate and 6 cycles of epirubicin, cyclophosphamide and fluorouracil Hormonal treatment was given routinely but mastectomies were not routinely performed. A high rate of locoregional control was obtained in 47 evaluable patients of whom 93.6 % achieved a complete clinical response. Three patients had locoregional relapses, always with concomitant metastatic dissemination. In 47 patients, 21 developed metastatic dissemination with a median delay of 23 months. Median disease-free survival (DFS) was 45 months. Median overall survival (OS) has not yet been reached after a median follow-up of 44.5 months. The 3-year DFS rate was 53 % and the 3-year OS rate was 71 %. Toxicity was mainly hematological. During the induction therapy, grade 3 or 4 neutropenia occurred in 54 % of patients, grade 3 or 4 thrombocytopenia in 23 % and grade 3 or 4 anemia in 8 %. The administration of induction chemotherapy and concomitant irradiation is feasible in patients with IBC. The hematological toxicity of this treatment approach is significant but nevertheless, the treatment achieves a high degree of locoregional control and improved survivaL

Guideline development: focus on breast cancer screening in the EsPeR project.

We describe in this paper, the implementation of a clinical practice guideline focused on breast cancer screening. Our aim in conceiving such a computerized guideline was first to help general practitioners in appreciating the risks their female patients might develop breast cancer and secondly to suggest them the screening measures adapted to each particular case. This implementation enables us to present our general methodology to elaborated and promulgate guidelines within the EsPeR project. This methodology aims at providing guidelines based on knowledge validated according to the EBM principles, that can be used in real time and updated according to current knowledge.

[The cost of breast cancer screening in France]. / Le coût du dépistage du cancer du sein en France.

PURPOSE: This paper presents the cost of two decentralised breast cancer screening programmes in France, in the Bas-Rhin and the Bouches du Rhône districts. Materials and methods. The costs directly related to running the two screening programmes were collected for the time period 1990-1997. Only direct costs of each programme, excluding assessment and treatment costs, are included in the cost analysis. Costs are presented per screening period, per programme attender and per cancer detected by screening. RESULTS: The screening programme costs an average of 397 francs per woman screened and 90,828 francs per cancer detected in the Bas-Rhin, and 379 francs and 76,159 francs, respectively, in the Bouches du Rhône. CONCLUSIONS: These costs are high compared to those of existing centralised programmes. Further research is needed to investigate means of ensuring the optimal efficiency of these programmes. The results of this study may help guide future decisions on the further development of breast cancer screening in France.

[Effects of hormone replacement therapy for menopause on prognostic factors of breast cancer]. / Effets des traitements hormonaux substitutifs de la ménopause sur les facteurs pronostiques des cancers du sein.

AIM: Hormone replacement therapy (HRT) is widely used by post-menopausal women. Although this treatment may slightly increase the incidence of breast cancer, more and more cases are diagnosed while women are taking HRT. The purpose of this study was to ascertain the influence of HRT on prognostic factors and outcome of breast cancer. Data on all breast cancer patients, including precise information on HRT, was prospectively and systematically recorded in a data base. PATIENTS AND METHODS: From 1990 to 1998, 1223 post-menopausal women fulfilled the eligibility criteria for this study. The clinical features, laboratory findings and survival rates in 245 HRT users who developed breast cancer while being treated were compared with those of 245 matched breast cancer patients who had never received HRT. RESULTS: Patients who developed breast cancer during HRT had fewer locally advanced cancers and smaller and better-differentiated cancers. Estradiol receptivity was quantitatively lower in users. Metastasis-free survival were better for the users. CONCLUSION: We conclude that HRT does not affect the prognosis of breast cancer. Regular surveillance during HRT allows early detection of smaller lesions. The higher number of well-differentiated cancers and the distribution of hormone receptivity may reflect interaction between neoplastic tissue and exogenous hormones.

Prognostic factors in ductal carcinoma in situ of the breast: results of a retrospective study of 575 cases. The Association for Research in Oncologic Gynecology.

OBJECTIVE: Conservative treatment for ductal carcinoma in situ of the breast exposes patients to the risk of infiltrating recurrence which can lead to metastasis. The primary purposes of this retrospective study were to evaluate diagnostic and therapeutic methods over a 10-year period and to validate prognostic factors. This information should greatly improve patient selection for conservative treatment or mastectomy. STUDY DESIGN: A multi-institutional data base including 575 patients treated between 1983 and 1993 was established by combining data from 16 French institutions. Survival at 5 and 7 years was studied as a function of various prognostic factors. RESULTS: Recurrence-free survival at 7 years was 0.96 after modified radical mastectomy and 0.83 after breast-conserving treatment and radiotherapy (P=0.003). Metastasis-free survival at 7 years was 0.99 after modified radical mastectomy and 0.94 after breast-conserving treatment and radiotherapy (not significant). No factor was predictive of local recurrence after mastectomy. Clinical stage was the only factor significantly correlated with metastasis after mastectomy. Recurrence-free survival after breast-conserving treatment with radiotherapy was significantly lower for patients with comedo carcinoma, multifocal lesions, or unclear resection margins, regardless of whether the histological type was comedo or non-comedo carcinoma. Metastasis-free survival was significantly lower for patients with multifocal lesions and for patients with unclear margins after excision of comedo carcinoma. CONCLUSIONS: Breast-conserving treatment with radiotherapy is a valid alternative to mastectomy. Patients must be selected carefully on the basis of morphological criteria. Swift gains in therapeutic outcome can be obtained by stressing quality control at each stage of diagnosis and treatment.

[Pelvic tumoral actinomycosis: a difficult diagnosis. Two case reports]. / L'actinomycose pelvienne tumorale: un diagnostic difficile. A propos de deux cas.

Two cases of intra-uterine device-associated occlusive pelvic pseudo-tumoural actinomycosis are presented. A pre-operative diagnosis of ovarian carcinoma was considered in both cases and lead to a wide and difficult surgery. Actinomycosis was confirmed by the postoperative histopathologic examination, and the patients were successfully treated with penicillin. The difficulties and limits of the clinical and histopathological diagnosis are exposed. The interest of the pre and intra-operative diagnosis which can avoid an extensive surgery with high morbidity is highlighted.

Impact of menopausal hormone-replacement therapy on clinical and laboratory characteristics of breast cancer.

Hormone-replacement therapy (HRT) is widely used by post-menopausal women. Although this treatment may slightly increase the incidence of breast cancer, more and more cases are diagnosed while women are taking HRT. The purpose of this study was to ascertain the influence of HRT on prognostic factors and outcome of breast cancer. Data on all breast-cancer patients, including precise information on HRT, was prospectively and systematically recorded in a data base. From 1985 to 1995, 1379 post-menopausal women fulfilled the eligibility criteria for this study. All were treated by us (P.B. and L.P.) in our ward of a large public hospital of Marseilles, France. The clinical features, laboratory findings and survival rates in 142 HRT users who developed breast cancer while being treated were compared with those of 284 matched never user breast-cancer patients. Patients who developed breast cancer during HRT had fewer locally advanced cancers and smaller and better-differentiated cancers. Lymph-node involvement was significantly less frequent in the user group than in the non-user group (non-significant). Estradiol receptivity was both qualitatively and quantitatively lower in users. There was no significant difference with regard to recurrence and metastasis-free survival and overall survival. We conclude that HRT does not affect the prognosis of breast cancer. Regular surveillance during HRT allows early detection of smaller lesions. The higher number of well-differentiated cancers and the distribution of hormone receptivity may reflect interaction between neoplastic tissue and exogenous hormones.

Treatment of carcinoma of the uterine cervix with concomitant cisplatin, 5-fluorouracil and split course hyperfractionated radiotherapy.

To improve local and systemic control of bulky (>4 cm) and/or advanced primary cancer of the uterine cervix, 35 patients were treated with concomitant cisplatin (CDDP), 5-fluorouracil (5-FU) and split course hyperfractionated radiotherapy. Radiation was administered to the pelvis in five-day courses at a dose of 1.5 Gy twice daily every 21 days until a median dose of 45 Gy was reached. 15 Gy more were administered to involved parametrium or central tumor by external radiotherapy or brachytherapy. The irradiated zone was extended to include paraaortic lymph nodes if necessary. CDDP was administered at a dose of 20 mg m(-2) and 5 FU at a dose of 500 mg m(-2) from day one to day five of each course. The median number of combined treatment courses per patient was four (1-6). Local responses were obtained in 19 out of 24 patients in whom evaluation was feasible (i.e. who did not undergo surgery prior to combined therapy). Median survival was not attained with a median follow up of 33 months, three year overall survival was 62% and 52% in patients with local control and in the whole population respectively. Several patients with stage III and IV tumors achieved a very long survival. Acute toxicity was manageable but three patients required surgical repair of late radiation complications. This combined chemotherapy and radiotherapy resulted in good local control and did not rule out surgery.

Diabetic mastopathy, complication of type 1 diabetes mellitus: report of two cases and a review of the literature.

The breast is not classically included among the organs damaged by diabetic complications. The first cases of breast lesions associated with Type 1 diabetes mellitus were only described in 1984. The disease, designated as diabetic or fibrous mastopathy, is benign but may clinically simulate breast carcinoma. Its frequency is difficult to evaluate, and its pathogenesis is not yet clearly understood. We report two cases of diabetic mastopathy, together with a review of the medical literature on this subject and a description of the main characteristics of the disease. Diagnosis is based on the clinical context (premenopausal women with longstanding Type 1 diabetes mellitus who develop a hard, painless, mobile lump on one or both breasts), radiology (dense glandular tissue on mammography and marked acoustical shadowing of sound waves on sonography), and histopathology (fibrosis and perivascular and periductal lymphocytic infiltration).

Influence of pregnancy on the outcome of breast cancer: a case-control study. Societe Francaise de Senologie et de Pathologie Mammaire Study Group.

The relationship between pregnancy and the outcome of breast cancer remains controversial. The purpose of this study was to determine the prognostic value of pregnancy at the time of diagnosis of primary infiltrating breast cancer. In a retrospective multi-center study we compared a group of 154 patients presenting pregnancy-associated (PA) breast cancer with a control group of 308 patients presenting non-pregnancy-associated (non-PA) breast cancer. Classic prognostic factors, treatment modalities, disease-free survival and overall survival were compared in the 2 groups. The relative importance of pregnancy was assessed by Cox multivariate analysis. There was a significantly higher proportion of inflammatory breast cancer, large tumors and negative receptor status in the PA group. Five-year recurrence-free survival, metastasis-free survival and overall survival were lower both in the whole PA group and in the PA sub-group excluding patients with inflammatory breast cancer than in the corresponding non-PA groups. According to clinical stage, histoprognostic grade and microscopic lymph-node involvement, probability of 5-year metastasis-free survival and overall survival was lower in the PA group. Outcome was significantly poorer after chemotherapy for patients in the PA sub-group than in the non-PA sub-group. Multivariate analysis demonstrated that pregnancy was an independent and significant prognostic factor. Pregnancy has an adverse effect on the outcome of breast cancer. Concurrent or recent pregnancy should be taken into account in the development of new systemic therapies. Our findings have important implications for further research into the basic mechanisms of cancer.

[Lymphocytic mastitis]. / Les mastites lymphocytaires.

Lymphocytic mastitis is a non infectious inflammatory disease of the breast with lobulocentric lymphocytic infiltrate of variable intensity, collagenous fibrosis and progressive lobular atrophy. The pathogenesis of lymphocytic mastitis is still unknown but some recent reports have suggested an autoimmune origin. We investigated a series of 10 cases by immunohistochemistry and we collected patients' biologic data. The most striking histologic feature was a prominent lobulocentric stromal or intraepithelial lymphocytic infiltrate. Occasionally, the infiltrate was perivascular and nodular along the lobule border. B and T lymphocytes, both demonstrated by immunophenotypic analysis, were shown with a particular pattern of distribution. Pathologists must be aware of this disease in order to recommend immunological investigation.

[Modalities of reading of detection mammographies of the programme in the Bouches-du-Rhône. Results and costs 1990-1995]. / Modalités de lecture des mammographies de dépistage du programme des Bouches-du-Rhône. Résultats et coûts 1990-1995.

In the Bouches du Rhône breast cancer screening programme, mammograms are read by two separate radiologists of different levels of training. All women with at least one positive reading are recalled for further assessment. During the first round, 3,477 of the 95,967 screenees were recalled by the first reader and 2,321 by the expert reader. The expert increased cancer detection by 15% and 45% of cancers detected by the expert were smaller than 11 mm. The marginal cost of double reading was 21,838 Francs per additional cancer detected. Double reading thus allowed for the detection of cancers of good prognosis which would have gone undetected by a single reader. Its cost seems justified by its impact on the effectiveness of the screening programme.

Quantitative immunocytochemical assays on frozen sections of p53: correlation to the follow-up of patients with breast carcinomas.

A series of 222 tumor samples stored at -80 degrees C in the authors' tumor library were investigated with anti-p53 (PA 1801) and streptavidin-biotin-peroxidase complex. The p53 immunoprecipitates were quantified by densitometry assessed by image analysis of digitized microscopic images. Two parameters, percentage of positive surface and mean optical densities, were compared with the patient's outcome (follow-up = 96.8 months) (life table method, Mantel Cox test, BMDP statistical software). The p53 expression significantly correlated with a poor overall survival (P = .0063), metastasis-free survival (P = .024), and recurrence-free survival (P = .022) at a 20% cutoff point of positive immunoreactive tumor surface. A strong prognostic significance was observed in the node-positive subset of patients but not in the node-negative subset, except for recurrence-free survival (P = .047). The results indicate the clinical relevance p53 evaluated by quantitative immunocytochemistry.