Prognostic and predictive indicators in early-stage breast cancer and the role of genomic profiling: Focus on the Oncotype DX® Breast Recurrence Score Assay.

Although useful prognostic and predictive insights can be gained from patient and tumour characteristics in early-stage breast cancer, it is not always straightforward to predict the likely risk of recurrence for each individual patient following breast surgery. One of the most difficult challenges faced by clinicians is identifying patients who may benefit most from adjuvant chemotherapy, and distinguishing these cases from those where endocrine therapy may be sufficient for cure. Genomic tests such as the Oncotype DX® Breast Recurrence Score® Assay have been developed to provide a robust and clinically validated assessment of a patient's individual tumour signature. The Oncotype DX Assay is included in treatment guidelines for estimating both the risk of distant recurrence and predicting adjuvant chemotherapy benefit for early-stage breast cancer patients with human epidermal growth factor receptor 2-negative, oestrogen-receptor positive, and axillary lymph node negative or positive (1-3 positive nodes) disease. In this article, we review unmet needs for prognostication and prediction in early-stage breast cancer, and consider how the information provided by the Recurrence Score is complementary to that gained from the assessment of more traditional clinicopathologic criteria. Routine use of the assay in clinical practice, limitations and possible future directions are also discussed.

Sequential taxane and anthracycline-containing neoadjuvant regimens: the sequential order impact.

BACKGROUND: One can consider as a standard neoadjuvant treatment for breast cancer, the sequence of 4 cycles of anthracycline-based chemotherapy followed by 4 cycles of docetaxel. Based on the belief that the sequence order between anthracycline and taxane might be of interest, this study assessed the impact of the sequence order. METHODS: One hundred and twenty three patients with breast cancer were treated with neoadjuvant chemotherapy in 5 oncologic centers between 2003 and 2007. This study compared 65 patients treated with 4 cycles of docetaxel followed by 4 cycles of anthracycline-based chemotherapy (cohort T), versus another cohort of 58 patients treated with 4 cycles of anthracycline-based chemotherapy followed by 4 cycles of docetaxel (cohort A). RESULTS: The overall dose intensity of docetaxel and clinical complete responses were significantly higher in cohort T. No statistically significant differences were observed in terms of conservative surgeries or histological responses. The sequence of chemotherapy did not significantly influence other treatment-related toxicities. Mild neurotoxicity was higher in patients treated in cohort T. Anemias (≥Grade 1) were higher in cohort A (52% versus 81%; p = 0.0008). CONCLUSION: The present study failed to identify an impact of the sequence of taxane administration on the efficacy. Nevertheless, starting neoadjuvant chemotherapy by taxane reduces the occurrence of anemia. These findings might allow a selection of the sequence order based on the toxicity profile.

[Radiation-induced breast angiosarcoma following breast-conserving therapy. Report of two cases]. / Angiosarcome mammaire radio-induit après traitement conservateur du cancer du sein. A propos de deux cas.

Breast angiosarcoma is a rare but serious complication of radiotherapy. We report two cases of radiation-induced breast angiosarcoma in two patients having benefited from breast conserving surgery with radiation. We shall put emphasis on the etiopathogeny of these tumours and their clinical and therapeutic aspects.

[Importance of human papillomavirus (HPV) screening in the follow-up after CIN2-3 treatment]. / Intérêt de la recherche du papillomavirus humain (HPV) dans le suivi post-conisation des CIN2-3. A propos de 386 cas.

INTRODUCTION: Cervical intraepithelial neoplasia (CIN) 2 and CIN3 lesions clearly represent precancerous states even if some of them would heal spontaneously. Management is based on surgical excision of part of the uterine cervix because such lesions can potentially progress into carcinomas. In most cases, this treatment leads to the cure of intraepithelial lesions. However, even after such an efficient treatment, theses patients are still at a higher risk of developing an invasive cervical cancer. That is why guidelines recommend a specific follow-up in order to screen for residual disease (incomplete excision) or for recurrences (after a complete excision). The actual problem in the follow-up strategy lies in the screening tools in use - cervical smears and colposcopy - whose sensitivities are low and hence, not quite sufficient when applied to a high risk population. These intraepithelial lesions are due to high risk human papillomaviruses (HPV) and there cannot be any lesion progression without HPV. Consequently, a viral testing would help in identifying a high risk subpopulation of women after cone loop cervical excision. MATERIAL AND METHODS: We studied, retrospectively, the contribution of HPV testing (Hybrid Capture 2((R))) in the follow-up after CIN2-3 treatment in 386 cone loop cervical excisions performed at a single centre during 80 months. RESULTS: Between three to six months follow-up after surgery, HPV remained present in 22.5% cases. The sensitivity of HPV testing in the screening for residual lesions or for recurrences was 100%, that of cervical smears cytology was 72%, whereas that of the pathological analysis of margins reached only 67%. The negative predictive value of a negative HPV detection associated with a normal cytology was 100%. DISCUSSION: Owing to its clinical relevance, HPV testing optimises postoperative follow-up and leads to the rapid and efficient selection of a subgroup, representing less than one upon three patients who are really at risk of an invasive lesion and to wholly reassure the others. Indeed, a negative HPV testing, associated with a normal cervical cytology, obtained after surgery correspond to a negative predictive value of almost 100% and this allows us to increase the time-interval between two screenings and to rapidly place the patient in a routine follow-up.

[Severe shoulder dystocia: study of 14 cases treated by Jacquemier's maneuver]. / La dystocie vraie des épaules: analyse de 14 cas traités par la manoeuvre de Jacquemier.

OBJECTIVE: Shoulder dystocia is a dreadful complication of vaginal deliveries since it can be responsible of brachial plexus palsies and even neonatal deaths. Unlike most studies, we defined shoulder dystocia as the enclosing of fetal shoulders above the superior strait (cavity station of 1cm) and situations being resolved only by delivery of the posterior arm (Jacquemier's maneuver). The purpose of this study was to analyze cases of shoulder dystocia in terms of maternal and neonatal complications and to compare risk factors with those identified in the literature. MATERIAL AND METHODS: We conducted a retrospective study of 14 cases of severe shoulder dystocia (SSD) which occurred at our hospital between January 1995 and January 2007. TSD was diagnosed in the absence of engagement of both fetal shoulders requiring recourse to Jacquemier's maneuver for delivery. Any gestational diabetes, abnormal progression of labour, suspicion or existence of fetal macrosomia, instrumental delivery, and neonatal complications were noted. RESULTS: The incidence of SSD was around 1 per thousand. Multiparity, weight gain greater than 15kg and gestational diabetes were moderately present in our study group. Only 20% of neonates were macrosomic and 50% had a birth-weight of less than 4000g. In 80% of cases, an instrumental extraction was practised. Brachial plexus injuries affected 20% of neonates, no fracture was observed, one child died following an unresolved SSD. CONCLUSION: This series shows that the incidence of SSD is rare and difficultly predictable even though identified risk factors exist. However, an instrumental extraction seems frequently associated with SSD and any extraction should take into account the presence of known risk factors. In spite of the severity of our cases of shoulder dystocia, complications found seemed to be similar to those observed in the literature.

[Life-threatening postpartum hemorrhage and recombinant activated factor rFVIIa NovoSeven use]. / Hémorragie de la délivrance "menaçant la vie" et utilisation du facteur VII recombinant activé rFVIIa NovoSeven.

Postpartum haemorrhage remains a dangerous obstetrical complication, which is the main cause of maternal mortality in developing countries. The diagnosis must be immediate and its management is both medically and surgically in life-threatening haemorrhage. We present a case of a thirty-three-year-old woman who asked a pregnancy interruption for premature rupture of membranes at 21(th) gestational week for her second pregnancy; she underwent a caesarean section at term for her first pregnancy. She delivered vaginally and developed a postpartum haemorrhage with hemorrhagic shock which was resistant to medical, surgical and radiological management. We decided to use recombinant activated factor VII (rFVIIa, NovoSeven) as a final attempt to rescue the patient. During surgery, two intravenous bolus injections (60, 120 mug/kg) were successfully given with a control of bleeding and haemoglobin. The patient developed later a splenic thrombosis that can be related to either rFVIIa or to the hypovolemic shock or to the sepsis. Recombinant activated factor VII is an interesting and promising haemostatic agent in the management of life-threatening postpartum haemorrhage unresponsive to conventional treatment.

[Cost effectiveness of Ligasure Precise versus surgical clips during axillary nodal dissection for breast cancer]. / Coût efficacité du Ligasure Precise versus clips chirurgicaux lors du curage axillaire pour cancer du sein.

UNLABELLED: Introduction. The techniques used for axillary node dissection are constantly evolving. The advent of the grip Ligasure Precise raise the question of its cost-effectiveness compared with surgical clips. OBJECTIVE: To compare the effectiveness of Ligasure compared with surgical clips for simple axillary node dissection or Patey procedure in terms of duration of drainage, cost of hospitalization and complications. MATERIAL: and method. Retrospective study extending from January 1, 2003 to December 31, 2004, concerning 187 patients who underwent simple axillary dissection (100) or Patey procedure (87), with use of surgical clips or Ligasure followed by drainage. RESULTS: The use of Ligasure increased the operative cost because its price is higher than that of a clip grip with a refill. Ligasure significantly decreased the duration of drainage in the two groups but there was significantly more abundant fluid loss in the dissection group. The cost of hospitalization related to the choice of the technique of hemostasis (cost of the material + lasted of drainage X price of the day of hospitalization), was not significantly favor of Ligasure. Taking into account the choice of the hemostasis technique and the total duration of hospitalization (material cost + duration of hospitalization X price of the day of hospitalization), there is no significant difference between the two groups. CONCLUSION: This study compares grip Ligasure Precise with surgical clips for axillary dissection. The duration of drainage was significantly shorter with Ligasure Precise but its benefit in terms of fluid loss remains to be shown. The use of Ligasure does not significantly reduce the cost of hospitalization.

[Obstetric and perinatal outcomes of a disreputable presentation: the nonfrank breech]. / Pronostic obstétrical et néonatal d'une présentation podalique de mauvaise réputation: le siège complet.

OBJECTIVES: A nonfrank breech is generally believed to be associated with abnormal labor and risk of cord prolapse. Owing to these risks, many authors consider such a presentation as a positive indication for cesarean section. The purpose of this study was to estimate the delivery characteristics of nonfrank breech with a gestational age over 37 weeks and particularities of this presentation. PATIENTS AND METHODS: This retrospective study included all deliveries with a nonfrank breech presentation and a gestational age over 37 weeks over a sixteen years period in our maternity ward. A descriptive analysis of maternal, fetal and obstetrical elements was carried out. RESULTS: 198 deliveries were indexed with 54% vaginal birth, regularly observed throughout the study period. Thirty percent delivered by prelabor planned cesarean section and 16% by cesarean section during labor. When a vaginal birth trial was allowed, at last 77.4% delivered by this route. Average labor time in the vaginal birth group was only 4.5 hours. Eleven cord prolapses were found (5.6%) of which more than half delivered by vaginal birth without fetal complications. Perinatal outcomes were satisfactory for the whole population, without differences between cesarean section and vaginal birth. DISCUSSION: Cord prolapse is a risk of nonfrank breech presentation but abnormal labor is not more frequent than with frank breech presentations if labor is managed rigorously. More than 75% patients of the vaginal birth trial group delivered by vaginal birth with perinatal outcomes as good as the cesarean section group. Unlike traditional reports, in our study a nonfrank breech was not an unfavorable factor for vaginal birth after strict selection of vaginal birth trial candidates.

Detection of cervical precancer and cancer in a hospital population; benefits of testing for human papillomavirus.

The aim was to determine the relevance of human papillomavirus (HPV) testing in identifying high-grade cervical intraepithelial neoplasia or worse (CIN2/3+) in a hospital population (n=3574) characterised by a high rate of cytological abnormalities and high-risk HPV infections. According to the results of the initial Papanicolaou and HPV test, women were directly referred for colposcopy/biopsy or recalled for a control visit. Sensitivity and specificity were corrected for verification bias. HPV-testing sensitivity was 94.3%, higher than that of cytological testing at any cut-off point (65.1%-86.8%), while specificity was greater for cytology than for HPV testing (99.3% or 91.8% versus 83.4%). The combination of both tests allowed 100% sensitivity and negative predictive value. We conclude that HPV testing is a relevant tool for the detection of cervical disease. The best way of combining cytology and HPV detection in screening programmes should be evaluated in large-scale studies.

[Maternal and fetal prognosis of occipito-posterior presentation]. / Pronostic maternel et foetal du dégagement en occipito-sacré.

Occipito-posterior persistent presentation is a relatively rare obstetrical condition, occurring in 2 to 4.5% of deliveries. Failure of the occiput to spontaneously rotate has been associated with increased maternal and neonatal morbidity. We performed a retrospective study of 210 vaginal occiput posterior deliveries to investigate the influence of this position on maternal and fetal morbidity. Our results demonstrate that overall prognosis of occipito-posterior persistent presentation is good but less auspicious than occipito-anterior presentation on account of importance of perineal injuries and maternal and fetal infections. Forceps extraction in posterior presentation is criticized today. In our opinion, the vacuum extractor is the better instrument because it is less aggressive to maternal tissues and also because, in most cases, the fetal head rotates anteriorly after provoked flexion.

[Ultrasonic diagnosis and laparoscopic treatment of an ovarian pregnancy. A case report and review of the literature]. / Diagnostic échographique et traitement laparoscopique d'une grossesse ovarienne. A propos d'un cas et revue de la littérature.

Ovarian pregnancy is an uncommon type of ectopic pregnancy. Incidence has been estimated at 1 per 7 000 pregnancies and 1 to 6% of ectopic pregnancies. Pathogenesis is different from tubal pregnancy. Generally it occurs as a single event in an otherwise healthy woman. Early diagnosis of ectopic pregnancy is essential and is now possible with the advent of endovaginal sonography associated with serum beta-hCG assay. There are various forms of ectopic pregnancies. Macroscopically, 4 forms can be distinguished: hematoma, clar ovum, embryonnized ovum, and placenta with fetus. Histology alone can confirm the diagnosis and distinguish between the 4 forms: intrafollicular, justafollicular, justacortical and interstitial pregnancy. For many authors, laparotomy is required in all cases, but in any case, the ovary can generally be preserved as implantation is usually superficial. We describe here a case of ovarian pregnancy after stimulated ovulation. Early diagnosis with correct localization was achieved with endovaginal sonography. Conservative treatment with laparoscopy was successful.

[Diagnosis of ovular infection associated with premature rupture of the membranes]. / Le diagnostic de l'infection ovulaire associée à la rupture prématurée des membranes.

Premature breaking of the membranes carries with it a serious risk of immediate or delayed ovular infection which compromises the prognosis. No diagnostic test with an acceptable error level was available to reduce the morbidity and mortality, in particular prior to 37 weeks of amenorrhea. The oligoamnios which accompanies the rupture increases the accuracy of the tocokinetic diagnosis, thus permitting a new and rigorous treatment in function of the stage of the pregnancy and the possibility of artificially inducing labor.