Overview of digital breast tomosynthesis: Clinical cases, benefits and disadvantages.

In France, the national breast cancer-screening program is based on mammography combined with clinical breast examination, and sometimes breast ultrasound for patients with high breast density. Digital breast tomosynthesis is a currently assessed 3D imaging technique in which angular projections of the stationary compressed breast are acquired automatically. When combined with mammography, clinicians can review both conventional (2D) as well as three-dimensional (3D) data. The purpose of this article is to review recent reports on this new breast imaging technique and complements this information with our personal experience. The main advantages of tomosynthesis are that it facilitates the detection and characterization of breast lesions, as well as the diagnosis of occult lesions in dense breasts. However, to do this, patients are exposed to higher levels of radiation than with 2D mammography. In France, the indications for tomosynthesis and its use in breast cancer-screening (individual and organized) are yet to be defined, as is its role in the diagnosis and staging of breast cancer (multiple lesions). Further studies assessing in particular the combined reconstruction of the 2D view using 3D tomosynthesis data acquired during a single breast compression event, and therefore reducing patient exposure to radiation, are expected to provide valuable insight.

[Reexcision for positive margins in the surgery of ductal carcinoma in situ: are there any risk factors?]. / Reprise chirurgicale des carcinomes canalaires in situ pour exérèse non in sano : existe-t-il des facteurs de risque ?

OBJECTIVES: Ductal carcinoma in situ (DCIS) is a common breast lesion (10% of breast cancers). In most of the cases the standard treatment is a partial mastectomy combined with adjuvant irradiation. However, when positive margins (<2mm) occur, surgical re-excision is necessary. The purpose of our study was to determine the rate of reoperation for positive margins in DCIS and identify potential preoperative risk factors of unhealthy margins. PATIENTS AND METHODS: This is a retrospective study of 63 patients. We collected cases of DCIS at the Lille and Valenciennes' hospitals from the 1st of January 2007 till the 1st of January 2012. RESULTS: Fifty patients have had a partial mastectomy and 28 patients (56%) have had one or two complementary interventions to get healthy resection margins. The pathologic tumor size (>10mm) appears to be a risk factor for positive margins. DISCUSSION AND CONCLUSION: Few studies were aimed at identifying risk factors for unhealthy margins for DCIS. The main risk factors found in the literature are: the presence of comedonecrosis, tumor greater than 10mm, a palpable tumor, the absence of a preoperative biopsy, the low-grade lesions. Our study confirmed the influence of tumor size greater than 10mm as a risk factor for positive margins.

Villoglandular papillary adenocarcinoma of the uterine cervix.

Villoglandular papillary adenocarcinoma of the uterine cervix was recently (1989) described by three main histological features: exophytic proliferation, papillary architecture and mild to moderate cellular atypicality. The authors report a case of villoglandular papillary adenocarcinoma, clinical stage IB, which was peculiar because of its association with a co-existing and simultaneously discovered invasive squamous cell carcinoma. These two patterns were juxtaposed and not intermingled. The patient was treated with radical hysterectomy followed by vaginal radiation therapy. She remains without evidence of recurrence after 12 months of follow-up. Five main clinicopathological features of the villoglandular papillary adenocarcinoma could be stressed: rare histological variant (72 described cases), young age of patients (25-45 years old), superficial stromal invasion, usual association with other tumoral patterns (in situ or invasive adenocarcinoma as well as in situ or invasive squamous cell carcinoma) and excellent prognosis. For selected cases, a conservative surgical approach (cervical conization) was possible.

[Appendicitis and pregnancy. Seven case reports]. / Appendicite et grossesse. A propos de 7 observations.

OBJECTIVES: Determiner optimal diagnosis and therapeutic management of pregnant women with suspected appendicitis. METHOD: Among over 9,000 patients who delivered in our obstetrics ward over a 4-year period, 7 (1/1, 285) underwent appendectomy during their pregnancy. Based on these observations and a review of the literature, an attempt was made to determine the best diagnostic approach in this rare situation. RESULTS: The frequency observed here was in agreement with data reported in the literature (1/1,000 to 1/2,000). Premature delivery occurred eight days after appendectomy at 29 months gestation in one woman. There was no complication in the 6 other pregnancies. Positive diagnosis, difficult during pregnancy, was based on clinical, biological and echographic findings. Laparoscopy improved not only diagnosis but also treatment and prognosis before 20 weeks gestation. CONCLUSION: Clinical presentation of appendicitis is modified during pregnancy rendering diagnosis difficult. The gravity of the appendicitis as well early diagnosis and management influence the maternal and fetal prognosis more than its association with pregnancy.

Immunological aspects of ovarian function: role of the cytokines.

Interaction between the immune system and reproduction is multiple. Either directly or indirectly through their products, immune cells are associated with the regulation of every level of the hypothalamus-pituitary-ovarian axis. Immune cells are present in the ovaries and their numbers increase during the cycle. During the follicular development cytokines assist granulosa cell growth while inhibiting their differentiation. During the LH peak, an influx of immune cells occurs and several cytokines are released. The rupture of the follicle is considered as an inflammatory reaction. IL-1, TNF-alpha are the main cytokines involved in this process. During the luteal phase, the installation of the corpus luteum needs the setting up of neovascularization. Cytokines are probable candidates for this function, but they also promote cellular differentiation resulting in steroid synthesis. In the absence of pregnancy T lymphocytes and eosinophils are involved in corpus luteum regression. Their products are directly cytotoxic for the luteal cells. They attract macrophages which are locally activated to phagocytose the damaged luteal cells. They can induce apoptosis of endothelial and luteal cells through gene expression. Cytokines are members of a larger regulatory network residing in the ovary and involving hormones and growth factors. The various stages of ovarian cycle will be shown from an immunological point of view. Understanding the role of the cytokines should enable us to go beyond a purely descriptive stage, and allow us to envisage new ovulation induction therapy and treatment in certain cases of premature menopause.

[Uterine rupture after twenty-two weeks of amenorrhea due to placenta praevia percreta. A case report]. / Rupture utérine à vingt-deux semaines d'aménorrhée par placenta praevia percreta. A propos d'une observation.

The authors report a case of rupture of the uterus 22 weeks after the LMP, due to placenta praevia percreta and requiring emergency hysterectomy to arrest bleeding, followed by urinary complications. With the predisposing factors of the scars of 4 previous cesarean sections and the low anterior insertion of the placenta, this exceptional case--in terms of its rarity and gravity--led the authors to undertake a review of the literature seeking other cases of this greatly feared obstetric complication. They review the clinical, ultrasonographic (notably the use of color Doppler) and paraclinical (MRI, cystoscopy) diagnostic approach necessary to make an accurate diagnosis of placenta percreta (if possible before any hemorrhagic complications). This situation virtually invariably requires hysterectomy to arrest bleeding, under very difficult conditions because of the massive hemorrhage involved. Mortality remains high and morbidity principally concerns the urinary complications frequently encountered.

[Physiopathology of pre-eclampsia: the role of immunology]. / Physiopathologie de la pré-éclampsie: place de l'immunologie.

Preeclampsia complicating 3% of all births is an important cause of maternal death and is associated with an increased risks of neonatal morbidity and mortality. Among the numerous theories proposed to explain this syndrome, the concept of placental ischaemia resulting in a generalized disturbance of endothelial physiology is receiving increasing support. Maternal immunological systems is often solicited during normal pregnancy. Most likely the immunological system is implicated in preeclampsia. Its responsibility is protean. Trophoblastic antigens may not be properly recognized by maternal immunologic system, resulting in a defect of trophoblastic invasion of the myometrial segment of the spiral arteries. Preeclampsia does not seem to be accompanied with trophoblast immunological rejection by the mother. Some cases of preeclampsia are associated with autoimmune phenomena. The autoantibodies could be directed against phospholipids or/and trophoblastic membrane components. Activated neutrophils release a variety of substances, capable of mediating vascular damage. An imbalance between the protective antioxidant activity and aggressive oxidant mechanisms could initiate the endothelial lesions. Preeclampsia could be one presentation of immunodystrophism with local excess of harmful cytokines. The immunologic system is probably not the initiator of preeclampsia, but its role is ambiguous: either the protective immunologic mechanisms usually operating during pregnancy can be surpassed, or immunologic responses are inadequate and directly aggressive. A better understanding of the underlying immunologic anomalies will improve the nosologic classification of preeclampsia syndrome.

Pregnancy after myocardial infarction.

UNLABELLED: The occurrence of pregnancy in a patient after myocardial infarction remains a dilemma for both the cardiologist and the obstetrician. The majority of obstetricians and cardiologists are very reticent about pregnancy in a woman suffering from coronary disease. AIMS: The aims of this study are to evaluate the risks, the prognosis of pregnancy for women who had suffered from myocardial infarction and to propose guidelines for pre-pregnancy counselling and medical supervision of the pregnancy and delivery. METHODS: A review of literature has revealed 30 cases, 14 of which are sufficiently documented. Only one of these patients requested pre-pregnancy counselling. We add to this experience the case of a patient who, having had an infarction, was authorized to begin pregnancy. RESULTS: Most of the pregnancies in these patients evolve satisfactorily if the more frequent cardiovascular complications are diagnosed and treated rapidly. During the pregnancy, rest is the rule and any situation which risks to increase the myocardial work-load should be avoided. Normal vaginal delivery with epidural anesthesia is the preferred method. CONCLUSION: The maternal and fetal prognosis is good on condition of performing a pre-pregnancy examination and of setting up a multi-discipline surveillance of the pregnancy. The review of the literature does not confirm the surrounding pessimism concerning the patients becoming pregnant after myocardial infarction.

[Laparoscopically-prepared vaginal hysterectomy. Our personal experiences (apropos of 35 cases)]. / Hystérectomies vaginales coelio-préparées. Notre expérience personnelle (à propos de 35 cas).

We report our personal experience with 35 laparoscopically prepared vaginal hysterectomies performed over a 3 year period, for January 1990 to January 1993. We give our indications for this new technique present our results. We compared our results with those reported in the literature evaluating indications, technique and complications and demonstrate the numerous advantages of this new technique. Finally, a decision protocol has been prepared in order to chose the optimal approach according to the preoperative work-up.

[Ovarian cysts. Diagnostic and therapeutic aspects]. / Kystes ovariens. Aspects diagnostiques et thérapeutiques.

The methods used to carry out exeresis of ovarian cysts by celioscopy are now familiar. Today, the main concern is the selection of annexial tumors appropriate for celiosurgical treatment in order to limit their use to benign organic cysts only. By comparing the results of a sery of 200 cysts which were treated surgically with cases in the literature, the authors conclude that the three-pronged use of clinical, ultrasound and macroscopic data in the diagnosis of malignant tumors is reliable. Progress remains to be made however in identifying functional cysts which are sometimes mistaken for an organic structure and all too often are still dealt with surgically. In order to reduce the incidence of such errors, new perspectives are envisaged, knowing that diagnostic error is often related to change in their ultrasound structure or their persistence despite conventional estro-progestogen treatment.

[Oral contraception]. / La contraception orale.

PIP: Because of their efficacy and ease of use, oral contraceptives (OCs) have become the most widespread contraceptive in France and the world. OCs also have the advantages of reversibility and increasing safety and innocuity due to lower doses of ethinyl estradiol (EE) and improved progestins. The contraceptive effect of OCs depends primarily on suppression of ovulation, endometrial atrophy, and modifications in the cervical mucus rendering it inhospitable to sperm. The three major types of OCs are combined pills of either standard or low dose, sequential pills, and low-dose progestins. Higher dose progestins may also be used for contraception but they are usually reserved for treatment of uterine and mammary pathology. Standard-dose combined OCs contain 50 mcg of EE, while low-dose formulations contain 20-40 mcg. Combined pills are monophasic, biphasic, or triphasic. The advantages of combined OCs are their great efficacy and antigonadotropic power, which allows total steroid doses to be reduced. They may however cause cycle problems due to endometrial atrophy. The long-term administration of EE alone for the first cycle phase with sequential pills has been shown to increase risks of breast disorders, endometrial dysplasia and uterine cancer. Sequential pills are now used only for short-term treatment in specific indications. Low-dose progestins provide a low and continuous dose of progestin. Ovulation is not always inhibited, and persisting secretion of LH and FSH involves some follicular maturation. Contraceptive efficacy relies solely on local effects on the cervical mucus, endometrial atrophy, and decreased tubal motility. The failure rate and incidence of ectopic pregnancy are higher and cycle problems are frequent. The only advantage is the absence of estrogen for women with contraindications. The side effects of combined OCs may include alterations of glucose tolerance and of lipid profiles, increases of blood pressure, modifications in coagulation factors leading to increased thromboembolic risk proportional to the estrogen dose, and increased risk of biliary lithiasis and certain types of jaundice. Combined OCs have not been formally proven to increase risk of cervical cancer, and they are known to have protective effects against ovarian tumors. Most adolescents tolerate standard-dose combined OCs quite well. Low-dose combined pills or high-dose progestins may be appropriate for women over 40. Combined OCs are contraindicated in cases of hypertension, although low-dose progestins may be prescribed. Combined OCs are contraindicated for many diabetics and in all cases of hyperlipidemia and in smokers over 35.^ieng

[Oral contraception: users' questions]. / Contraception orale: questions des utilisatrices.

PIP: Answers are provided to common questions about the safety and use of oral contraceptives (OCs). Amenorrhea during OC use has no pathologic significance. It is related to endometrial atrophy resulting from insufficient estrogen after longterm pill use. A formulation with a higher estrogen content may be used for one or two cycles to regenerate the endometrium. If amenorrhea persists for more than a few months after discontinuation of pills, pituitary adenoma should be ruled out. Bromocriptine may be indicated in cases of moderate hyperprolactinemia if pregnancy is desired. All intermenstrual bleeding in pill users should be investigated for organic cause. Once endometrial polyps and other pathologies are ruled out, the cause may be assumed to be functional metrorrhagia due to endometrial atrophy identical to that causing amenorrhea in OC users. Intermenstrual bleeding may occasionally result from interactions with specific classes of drugs. Minor bleeding in the first cycles of pill use is common and usually temporary. Accidentally taking two pills in one day is without consequence. If the interval between pill cycles exceeds one week, there is risk of follicular maturation and a different contraceptive method should be used until the next cycle. Forgetting a combined pill is without consequence for delays of under twelve hours. Another method should be used until the next cycle if two pills are forgotten. Low-dose oral progestins rapidly lose efficacy if not taken at the same time every day. "Morning-after" pills may be used up to 72 hours after unprotected intercourse. The current generation of OCs entails no teratogenic risks. The cause of any pill failure should be sought. There is no increased risk of multiple pregnancy after discontinuation of pills, and fecundity does not decline after longterm pill use. OCs should be avoided by users of some antiepileptic drugs or of drugs that increase hepatic toxicity or act as enzyme inductors. All conditions accompanied by hepatic insufficiency or cholestasis are formal contraindications to pill use. The effect of OCs on development of vaginal mycoses is unclear. OCs may be an effective treatment for dysmenorrhea because of their antiprostaglandin properties and reduced flow.^ieng