Prospective multicenter comparison of models to predict four or more involved axillary lymph nodes in patients with breast cancer with one to three metastatic sentinel lymph nodes.

PURPOSE: Three models have been developed to predict four or more involved axillary lymph nodes (ALNs) in patients with breast cancer with one to three involved sentinel lymph nodes (SLNs). Two scores were developed by Chagpar et al (Louisville scores excluding or including method of detection), and a nomogram was developed by Katz et al. The purpose of our investigation was to compare these models in a prospective, multicenter study. PATIENTS AND METHODS: Our study involved a cohort of 536 patients having one to three involved SLNs who underwent ALN dissection. We evaluated the area under the receiver operating characteristic curve (AUC), calibration (for the Katz nomogram only), false-negative (FN) rate, and clinical utility of the three models. Results were compared with the optimal logistic regression (OLR) model that was developed from the validation cohort. RESULTS: Among the 536 patients, 57 patients (10.6%) had > or = four involved ALNs. The AUC for the Katz nomogram was 0.84 (95% CI, 0.81 to 0.86). The Louisville score excluding method of detection was 0.75 (95% CI, 0.72 to 0.78). The Louisville score including method of detection was 0.77 (95% CI, 0.74 to 0.79). The FN rates were 2.5% (eight of 321 patients), 1.8% (two of 109 patients), and 0% (zero of 27 patients) for the Katz nomogram and the Louisville scores excluding and including method of detection, respectively. The Katz nomogram was well calibrated. Optimism-corrected bootstrap estimate AUC of the OLR model was 0.86. Using this result as a reasonable target for an external model, the performance of the Katz nomogram was remarkable. CONCLUSION: We validated the three models for their use in clinical practice. The Katz nomogram outperformed the two other models.

Hysteroscopic evaluation of endocervical and endometrial lesions observed after different procedures of embryo transfer: a prospective comparative study.

OBJECTIVE: Endocervical and endometrial damage observed after different procedures of embryo transfer (ET) were investigated using diagnostic hysteroscopy. STUDY DESIGN: Prospective, descriptive and comparative study, in an Infertility centre, University Hospital. Hundred consecutive infertile patients with a normal uterine cavity, included in an IVF program, were enrolled between May 1st, 2006 and April 30th, 2007. All the patients had a diagnostic hysteroscopy immediately after trial ET using soft ET catheters: (i) IVF Sydney Set (Cook, Limerick, Ireland) (n=27), (ii) Elliocath (Ellios, Paris, France) (n=34), (iii) Frydman classic 4.5 (CCD, Paris, France) (n=19), and rigid ET catheters: Memory Frydman 4.5 (CCD, Paris, France) (n=20). All the procedures were recorded and blindly reviewed. Data were analyzed using a Kruskal-Wallis test for age and severity of endometrial lesions, or Fisher's exact test for binary criteria. RESULTS: Endocervical lesions were more frequently encountered in the soft (63%) and rigid (85%) Frydman's catheter groups compared to other groups (Elliocath: 29%, IVF Sydney Set: 26%; p<0.0001). Presence of blood on the catheter, and endometrial lesions were significantly less frequent in soft catheter groups compared to the rigid catheter group (p<0.0001). Severe endometrial lesions were less frequently observed when soft catheters were used (85%, 53%, 32%, 11% for Memory Frydman, Frydman classic, Elliocath and IVF Sydney Set, respectively; p<0.0001). The presence of blood on the catheter signed severe endometrial lesions. CONCLUSION: All ET catheters can lead to endocervical and endometrial damage. Severe endometrial lesions were less frequent when soft catheters were used.

Prevalence and predictive factors for the detection of carcinoma in cavity margin performed at the time of breast lumpectomy.

Margin resection status is a major risk factor for the development of local recurrence in breast conservation therapy for carcinoma. Tumor bed excision sent as separate orientated cavity margins represents a tool to verify the completeness of the carcinoma resection. We aimed to (1) determine the prevalence of positive cavity margin and its influence on subsequent surgical treatment and (2) identify potential predictive factors for positive cavity margins. From 2003 to 2006, 107 (57 years; 30-88) consecutive patients who underwent a lumpectomy for carcinoma with four orientated cavity margins for carcinoma were selected. Preoperative clinical, radiological and histological data, perioperative macroscopic characteristics and definitive histological analysis results were recorded. Lumpectomy or cavity margins were considered as positive when the distance from carcinoma to the margin was less than or equal to 3 mm. Histological examination of cavity margins showed carcinoma in 38 patients (35%), therefore modifying subsequent surgical therapy in 33 cases. Examination of the cavity margins led (1) to avoiding surgical re-excision in 20 cases (lumpectomy margins were positive and the cavity margins negative), (2) to performing a mastectomy or a re-excision in 13 cases (carcinoma was detected in the cavity margins although the lumpectomy margins were negative or tumor size was superior to 3 cm). Between preoperative and perioperative parameters, US scan and macroscopic size of the tumor were predictive factors for positive cavity margins whereas characteristics of the carcinoma determined on biopsy samples and macroscopic status of the lumpectomy margins were not. Our study confirms that the systematic practice of cavity margin resection avoids surgical re-excision and reduces the likelihood of underestimating the extent of the tumor.

Albumin liver dialysis as pregnancy-saving procedure in cholestatic liver disease and intractable pruritus.

Progressive familial intrahepatic cholestasis type 3 (PFIC3) is a rare cholestatic liver disease. Such liver disease can get worse by female hormone disorder. Albumin dialysis or Molecular Adsorbent Recirculating System (MARS) has been reported to reverse severe cholestasis-linked pruritus. Here, we report the first use of MARS during a spontaneous pregnancy and its successful outcome in a patient with PFIC3 and intractable pruritus. Albumin dialysis could be considered as a pregnancy-saving procedure in pregnant women with severe cholestasis and refractory pruritus.

Management of hydrosalpinx before or during in vitro fertilization-embryo transfer: a national postal survey in France.

Using an anonymous and sealed questionnaire sent to all French IVF centers, the current management of hydrosalpinx before or during IVF was evaluated. Laparoscopic salpingectomy was recommended and undertaken in less than half of the centers, even though several other treatments were reported and despite medical evidence for this surgical option.

Doppler and immunohistochemical evaluation of decidual spiral arteries in early pregnancy.

OBJECTIVE: The purpose of this study was to estimate spiral artery subchorionic flow at 8-11 gestational weeks (GW) by Doppler ultrasound and then to analyze these vessels in the decidua basalis using histologic, morphometric and immunohistochemical analyses. METHODS: Subchorionic spiral arteries were evaluated in 5 women scheduled for aspiration at 8-11 GW. Flow velocity waveforms were sought using color and pulsed Doppler, and the diastolic/systolic (D/S) index was calculated. Transcervical biopsy specimens and aspiration products were thoroughly examined to investigate the structure of the spiral artery at the implantation site using cytotrophoblastic and arterial smooth muscle cell immunohistochemical markers (anti-cytokeratin 7 and anti-actin monoclonal antibodies). Spiral artery cross-sectional inner areas were measured and compared with the D/S index in each case. RESULTS: Low-impedance pulsatile flow could be detected below the trophoblastic ring in all cases. Complete obstruction of a spiral artery lumen was never observed and cytotrophoblastic cells were incorporated into the vessel wall starting from the perivascular cuff. CONCLUSION: Both techniques evidenced that decidual spiral arteries in the placental bed are not completely obstructed at 8-11 GW.

IgM and IgG autoantibodies from microscopic polyangiitis patients but not those with other small- and medium-sized vessel vasculitides recognize multiple endothelial cell antigens.

Using a quantitative immunoblotting technique on extracts of macrovascular and microvascular endothelial cells (EC), we analyzed serum IgM and IgG reactivities of patients with active disease fulfilling the ACR and Chapel Hill criteria for the diagnosis of polyarteritis nodosa (PAN) (n = 8), PAN related to hepatitis B virus (HBV) infection (HBV-PAN) (n = 5), Wegener's granulomatosis (n = 6), microscopic polyangiitis (MPA) (n = 18), Churg-Strauss syndrome (n = 8), and patients with chronic HBV infection without PAN (n = 5) and age- and gender-matched healthy individuals (n = 45). MPA patients' IgM bound to 200-, 105-, 80-, 65-, 45-, 35-, and 33-kDa major bands, whereas IgM from controls and other patients bound predominantly to the 65-kDa band in EC extracts. MPA patients' IgG reacted mainly with 105-, 70-, 55-, and 38-kDa protein bands, whereas IgG from controls and other patients did not. Our results provide evidence that IgM and to a lesser degree IgG from MPA patients specifically recognize multiple EC antigens.

Down syndrome maternal serum marker screening after 18 weeks' gestation.

Women having access to prenatal care late in pregnancy may still wish to benefit from maternal serum screening for Down syndrome. Therefore, we established reference values for alpha-feto protein (AFP) and free beta-human chorionic gonadotrophin (beta-hCG), and assessed the diagnostic value of maternal serum marker screening at 18-35 weeks' gestation based upon a series of 4072 sera from unaffected pregnancies and 118 sera from pregnant women with fetuses affected by Down syndrome. Using a 1/250 risk cut-off, a detection rate of 72.9% (95% CI = 71.5-74.3%) was achieved with a false-positive rate of 7.51% (95% CI = 6.71-8.3%). This was not significantly different from the percentages observed in our 14-17 weeks routine screening (50 596 patients): 71.9% (95% CI = 71.5-72.3%) and 6.48% (95% CI = 6.28-6.68%), respectively. Detection and screen-positive rates were, respectively, 51.3% (95% CI = 35.6-67.0%) and 5.95% (95% CI = 5.12-6.68%) in women aunder 35 years of age, and 84.8% (95% CI = 76.9-92.7%) and 24% (95% CI = 20.7-27.3%) in women aged 35 years and over. In conclusion, maternal serum marker screening is feasible at 18 weeks' gestation and later, which may be of interest in selected cases.

Operable Stages IB and II cervical carcinomas: a retrospective study comparing preoperative uterovaginal brachytherapy and postoperative radiotherapy.

PURPOSE: To evaluate our data concerning prognostic factors and treatment toxicity in a series of operable cervical carcinomas. METHODS AND MATERIALS: Between May 1972 and January 1994, 414 patients with cervical carcinoma, staged according to the 1995 FIGO staging system (286 Stage IB1, 38 Stage IB2, 56 Stage IIA, and 34 Stage IIB with 1/3 proximal parametrial involvement), underwent radical hysterectomy with (n = 380) or without (n = 34) bilateral pelvic lymph node dissection (N+: n = 68). Group I included 168 patients who received postoperative radiation therapy (RT): 64 patients had low-dose-rate vaginal brachytherapy with a median total dose (MTD) of 50 Gy; 93 patients had external beam pelvic RT (EBPRT) with an MTD of 45 Gy over 5 weeks, followed by low-dose-rate vaginal brachytherapy (MTD: 20 Gy); and 11 patients had EBPRT alone (MTD: 50 Gy over 6 weeks). Group II included 246 patients treated with preoperative low-dose-rate uterovaginal brachytherapy (MTD: 65 Gy); 32 of these 246 patients also received postoperative EBPRT (MTD: 45 Gy over 5 weeks) delivered to the parametria and pelvic nodes. Mean follow-up from the beginning of treatment was 106 months. RESULTS: First events included isolated locoregional recurrences (35 patients), isolated distant metastases (27 patients), and locoregional recurrences with synchronous metastases (13 patients). The 10-year disease-free survival (DFS) rate was 88% for Stage IB1, 44% for Stage IB2, 65% for Stage IIA, and 48% for Stage IIB. Multivariate analysis showed that independent factors influencing the probability of DFS were as follows: cervical site (exocervical or endocervical vs. both endo- and exocervical, relative risk [RR]: 1.77, p = 0.047), vascular space invasion (no vs. yes, RR: 1.95, p = 0.041), age (>51 years vs. 1 cm: 83% vs. 41%, respectively, p = 0.001). The overall postoperative complication rate was 10% in Group I and 9% in Group II (p = 0.7). The rate of postoperative ureteral complications requiring surgical intervention was lower in Group I than in Group II (0.6% vs. 2.3%, respectively, p = 0.03). The overall 10-year rate for Grade 3 and 4 late radiation complications was 10.4%. Postoperative EBPRT significantly increased the 10-year rate for Grade 3 and 4 late radiation complications (yes vs. no: 22% vs. 7%, respectively, p = 0.0002). CONCLUSION: The prognosis for patients with cervical carcinoma was not influenced by the sequence of adjuvant RT (preoperative uterovaginal brachytherapy vs. postoperative RT) for Stages IB, IIA, and IIB with 1/3 proximal parametrial involvement. However, postoperative EBPRT increased the risk of late radiation complications.

Various Doppler sonographic appearances and challenges in prenatal diagnosis of vasa praevia.

Rupture of vasa praevia is associated with a high rate of fetal or neonatal mortality. Since the recent development of color and spectral Doppler sonography, prenatal diagnosis of vasa praevia has been increasing but is not yet consistent. We report 2 cases that were diagnosed prenatally, enabling cesarean section to be performed under optimal conditions to prevent complications. A better knowledge of the characteristic Doppler sonographic appearances and the risk factors associated with vasa praevia could greatly facilitate the prenatal diagnosis of this condition and hence the fetal prognosis.

[Indication for labor induction by prostaglandin E2 vaginal gel. Retrospective study of a continuous series of 170 patients]. / Indication de l'induction du travail par gel vaginal de prostaglandine E2. Etude rétrospective d'une série continue de 170 patientes.

OBJECTIVE: To assess the factors of efficacy, side effects and complications following vaginal application of prostaglandin E2 (PGE2). METHODS: Retrospective study of 170 women in whom a PGE2 vaginal gel was administered between June 1, 1999 and June 1, 2000. The efficacy (labor effectively induced), quality of myometrial response, side effects and complications were studied globally and in each clinical context: intra-uterine delayed growth (IUDG), pre-eclampsia without IUDG, diabetes, pregnancy prolonged without IUDG, anomaly in fetal heart rate (FHR) and/or in amniotic liquid without IUDG discovered during the systematic monitoring at the end of pregnancy, premature rupture of the membrane without IUDG. RESULTS: The overall success (defined as the onset of labor) was of 94.1%. This rate was of 90.7% in primiparous and of 100% in multiparous women. Twenty-three patients (13.5%) experienced side effects (hyperkinesia or hyperthermia) and 35 patients (20.6%) complications (hyperkinesia or hypertonia with fetal repercussion). The maternal-response to infection was significantly improved (p < 0.05) in cases of prolonged rupture of the membranes or anomaly discovered during monitoring, but only in patients with diabetes. In cases of IUDG of vascular etiology with multiparity, the total quantity of PGE2 necessary was only of 1.14 mg and 85% of patients subsequently delivered without ocytocine. CONCLUSION: IUDG and prolonged pregnancy are the principle indications for PGE2 vaginal gels. The quality of response depends on the clinical context. In cases of premature rupture of the membranes or of anomaly discovered during monitoring (FHR and amniotic liquid), response was only improved in diabetic patients. In cases of vascular IUDG and multiparity, the response was excellent and the majority of women subsequently delivered without ocytocine, thus confirming the quality of myometrial response. Hence, the quantity of PGE2 required varied, depending on the subjecent pathology. This strategy could limit the risk of excessive myometrial response (hyperkinesia or hypertonia) and thus improve fetal tolerance.

Comparison of the effectiveness of recombinant and urinary FSH preparations in the achievement of follicular selection in chronic anovulation.

In order to compare the effectiveness of urinary and recombinant FSH (rFSH) preparations in achieving the threshold of follicular growth, stimulated cycles from patients with chronic anovulation, treated with a constant dose of FSH until the emergence of a selected follicle, were retrospectively analysed. Sixty-four cycles were performed using a similar starting dose of either urinary FSH (group 1) or rFSH (group 2), which was kept constant up to the time of follicular selection, assessed on ultrasound (follicular diameter >10 mm). The results of this study showed that, while the number of selected follicles was similar, the mean daily FSH dose required to achieve the threshold of follicular selection was significantly lower in group 2 (70.4 +/- 3.4 IU/day) than in group 1 (86.5 +/- 4 IU/day; P < 0.005). Furthermore, at the time of human chorionic gonadotrophin (HCG) administration, the total FSH dose was significantly lower in group 2 than in group 1, but plasma oestradiol values were equivalent. These data suggest that the higher effectiveness of rFSH preparations over urinary ones may be explained by a lower threshold dose required to achieve follicular selection.