Interventions that Facilitate Shared Decision-Making in Cancers with Active Surveillance as Treatment Option: a Systematic Review of Literature.

PURPOSE OF REVIEW: Medical decisions concerning active surveillance are complex, especially when evidence on superiority of one of the treatments is lacking. Decision aids have been developed to facilitate shared decision-making on whether to pursue an active surveillance strategy. However, it is unclear how these decision aids are designed and which outcomes are considered relevant. The purpose of this study is to systematically review all decision aids in the field of oncological active surveillance strategies and outcomes used by authors to assess their efficacy. RECENT FINDINGS: A search was performed in Embase, Medline, Web of Science, Cochrane, PsycINFO Ovid and Google Scholar until June 2019. Eligible studies concerned interventions aiming to facilitate shared decision-making for patients confronted with several treatment alternatives, with active surveillance being one of the treatment alternatives. Twenty-three eligible articles were included. Twenty-one articles included patients with prostate cancer, one with thyroid cancer and one with ovarian cancer. Interventions mostly consisted of an interactive web-based decision aid format. After categorization of outcomes, seven main groups were identified: knowledge, involvement in decision-making, decisional conflict, treatment preference, decision regret, anxiety and health-related outcomes. Although active surveillance has been implemented for several malignancies, interventions that facilitate shared decision-making between active surveillance and other equally effective treatment alternatives are scarce. Future research should focus on developing interventions for malignancies like rectal cancer and oesophageal cancer as well. The efficacy of interventions is mostly assessed using short-term outcomes.

Prevention of incisional hernia after midline laparotomy with prophylactic mesh reinforcement: a meta-analysis and trial sequential analysis.

BACKGROUND: Incisional hernia is a frequent complication after abdominal surgery. The aim of this study was to assess the efficacy of prophylactic mesh reinforcement (PMR) after midline laparotomy in reducing the incidence of incisional hernia. METHODS: A meta-analysis was conducted following PRISMA guidelines. The primary outcome was the incidence of incisional hernia after follow-up of at least 12 months. Secondary outcomes were postoperative complications. Only RCTs were included. A random-effects model was used for the meta-analysis, and trial sequential analysis was conducted. RESULTS: Twelve RCTs were included, comprising 1815 patients. The incidence of incisional hernia was significantly lower after PMR compared with sutured closure (risk ratio (RR) 0·35, 95 per cent c.i. 0·21 to 0·57; P < 0·001). Both onlay (RR 0·26, 0·11 to 0·67; P = 0·005) and retromuscular (RR 0·28, 0·10 to 0·82; P = 0·02) PMR led to a significant reduction in the rate of incisional hernia. The occurrence of seroma was higher in patients who had onlay PMR (RR 2·23, 1·10 to 4·52; P = 0·03). PMR did not result in an increased rate of surgical-site infection. CONCLUSION: PMR of a midline laparotomy using an onlay or retromuscular technique leads to a significant reduction in the rate of incisional hernia in high-risk patients. Individual risk factors should be taken into account to select patients who will benefit most. [Correction added on 19 February 2020, after first online publication: J. García Alamino has been amended to J. M. Garcia-Alamino].

ANTECEDENTES: La eventración (hernia incisional) es una complicación frecuente de la cirugía abdominal. El objetivo es evaluar la eficacia de la inserción de una malla profiláctica de refuerzo (prophylactic mesh reinforcement, PMR) después de la laparotomía media para reducir la incidencia de eventración. MÉTODOS: Se realizó un metaanálisis siguiendo las recomendaciones PRISMA. La variable principal fue la incidencia de eventración después de un seguimiento mínimo de 12 meses. Las variables secundarias fueron las complicaciones postoperatorias. Solo se incluyeron ensayos controlados aleatorizados. Se utilizó un modelo de efectos aleatorios para el metaanálisis y se realizó un análisis secuencial de los ensayos. RESULTADOS: Se incluyeron 12 ensayos aleatorizados y controlados con 1.815 pacientes. La incidencia de eventración fue significativamente menor después de la PMR en comparación con el cierre simple (riesgo relativo, RR 0,35; i.c. del 95%: 0,21-0,57, P < 0,0001). Hubo una reducción significativa de la tasa de eventración tanto si la PMR se colocó en posición supra-aponeurótica (RR 0,26; i.c. del 95% 0,11-0,67, P = 0,005) como retromuscular (RR 0,28; i.c. del 95% 0,0-0,82, P = 0,02). La aparición de seromas fue mayor en los pacientes con RPM supra-aponeurótica (RR 2,23; i.c. del 95% 1,10-4,52, P = 0,03). La PMR no conllevó una mayor tasa de infecciones de la herida quirúrgica. CONCLUSIÓN: Una PMR en una laparotomía de la línea media, tanto en posición supra-aponeurótica como retromuscular, reduce de forma significativa el desarrollo de eventraciones en pacientes de alto riesgo. Se deben considerar los factores de riesgo individuales para seleccionar a los pacientes que más puedan beneficiarse.

Nationwide comprehensive gastro-intestinal cancer cohorts: the 3P initiative.

BACKGROUND: The increasing sub-classification of cancer patients due to more detailed molecular classification of tumors, and limitations of current trial designs, require innovative research designs. We present the design, governance and current standing of three comprehensive nationwide cohorts including pancreatic, esophageal/gastric, and colorectal cancer patients (NCT02070146). Multidisciplinary collection of clinical data, tumor tissue, blood samples, and patient-reported outcome (PRO) measures with a nationwide coverage, provides the infrastructure for future and novel trial designs and facilitates research to improve outcomes of gastrointestinal cancer patients. MATERIAL AND METHODS: All patients aged ≥18 years with pancreatic, esophageal/gastric or colorectal cancer are eligible. Patients provide informed consent for: (1) reuse of clinical data; (2) biobanking of primary tumor tissue; (3) collection of blood samples; (4) to be informed about relevant newly identified genomic aberrations; (5) collection of longitudinal PROs; and (6) to receive information on new interventional studies and possible participation in cohort multiple randomized controlled trials (cmRCT) in the future. RESULTS: In 2015, clinical data of 21,758 newly diagnosed patients were collected in the Netherlands Cancer Registry. Additional clinical data on the surgical procedures were registered in surgical audits for 13,845 patients. Within the first two years, tumor tissue and blood samples were obtained from 1507 patients; during this period, 1180 patients were included in the PRO registry. Response rate for PROs was 90%. The consent rate to receive information on new interventional studies and possible participation in cmRCTs in the future was >85%. The number of hospitals participating in the cohorts is steadily increasing. CONCLUSION: A comprehensive nationwide multidisciplinary gastrointestinal cancer cohort is feasible and surpasses the limitations of classical study designs. With this initiative, novel and innovative studies can be performed in an efficient, safe, and comprehensive setting.

The idiosyncratic drug-induced gene expression changes in HepG2 cells.

The inflammatory stress has been associated with an increase in susceptibility to idiosyncratic drug-induced liver injury (DILI). However, the molecular mechanisms of this inflammation-associated idiosyncratic drug hepatotoxicity remain unknown. We exposed HepG2 cells with high and low doses of three idiosyncratic (I) and three non-idiosyncratic (N) compounds, in the presence (I+ and N+) or absence (I- and N-) of a cytokine mix for 6, 12 and 24 h. To investigate the genome-wide expression patterns, microarray was performed using the Agilent 4×44K Whole Human Genome chips. The data presented in this DIB include the expression of genes participating in the ceramide metabolism, ER stress, apoptosis and cell survival pathways. The functions of these genes were illustrated in our associated article (Jiang et al., 2017) [1]. Raw and normalized gene expression data are available through NCBI GEO (accession number GSE102006).

Omics-based identification of the combined effects of idiosyncratic drugs and inflammatory cytokines on the development of drug-induced liver injury.

The mechanisms of idiosyncratic drug-induced hepatotoxicity remain largely unclear. It has demonstrated that the drug idiosyncrasy is potentiated in the context of inflammation and intracellular ceramides may play a role in this process. To study the mechanisms, HepG2 cells were co-treated with high and low doses of three idiosyncratic (I) and three non-idiosyncratic (N) compounds, with (I+ and N+) or without (I- and N-) a cytokine mix. Microarray, lipidomics and flow cytometry were performed to investigate the genome-wide expression patterns, the intracellular ceramide levels and the induction of apoptosis. We found that all I+ treatments significantly influenced the immune response- and response to stimulus-associated gene ontology (GO) terms, but the induction of apoptotic pathways, which was confirmed by flow cytometry, only appeared to be induced after the high-dose treatment. The ceramide signaling-, ER stress-, NF-kB activation- and mitochondrial activity-related pathways were biologically involved in apoptosis induced by the high-dose I+. Additionally, genes participating in ceramide metabolism were significantly altered resulting in a measurable increase in ceramide levels. The increases in ceramide concentrations may induce ER stress and activate the JNK pathway by affecting the expression of the related genes, and eventually trigger the mitochondria-independent apoptosis in hepatocytes. Overall, our study provides a potential mechanism to explain the role of inflammation in idiosyncratic drug reactions.

Treatment of extra-articular proximal and middle phalangeal fractures of the hand: a systematic review.

The aim of the study was to systematically review the patient reported and functional outcomes of treatment for extra-articular proximal or middle phalangeal fractures of the hand in order to determine the best treatment options. The review methodology was registered with PROSPERO. A systematic literature search was conducted in electronic bibliographic databases. Two independent reviewers performed screening and data extraction. The evaluation of quality of the included studies was performed using the Structured Effectiveness Quality Evaluation scale. The initial search yielded 2354 studies. The full text manuscripts of 79 studies were evaluated of which 16 studies met the inclusion criteria. In total, 513 extra-articular proximal and middle phalangeal fractures of the hand were included of which 118 (23%) were treated non-operatively, 188 (37%) were treated by closed reduction internal fixation (CRIF) and 207 (40%) by open reduction internal fixation. It can be recommended that closed displaced extra-articular phalangeal fractures can be treated non-operatively, even fractures with an oblique or complex pattern, provided that closed reduction is possible and maintained. Conservative treatment is preferably performed with a cast/brace allowing free mobilization of the wrist. No definite conclusion could be drawn upon whether closed reduction with extra-articular K-wire pinning or transarticular pinning is superior; however, it might be suggested that extra-articular K-wire pinning is favoured. When open reduction is necessary for oblique or spiral extra-articular fractures, lag screw fixation is preferable to plate and screw fixation. But, similar recovery and functional results are achieved with transversally inserted K-wires compared to lag screw fixation. TYPE OF STUDY/LEVEL OF EVIDENCE: therapeutic III.

[Correlation between ICIQ-UI-SF score and personality testing results over a urinary incontinent population]. / Corrélation entre le score de l'ICIQ-UI-SF et les résultats d'un test psychométrique de personnalité d'une population ayant une incontinence urinaire.

OBJECTIVE: We found out the personality pattern of an incontinent population and proceeded to a correlation between the personality inventory and the ICIQ-UI-SF (International Consultation Incontinence Questionnaire Urinary Incontinence Short Form) to demonstrate reliability and sincerity of the answers and to establish that a personality disturbance may impact the physiopathology of micturition. MATERIALS AND METHODS: We performed an observational prospective study. It included patient's answers to a computed questionnaire combining a double ICIQ-UI-SF questionnaire and the 71 questions of the Minimult questionnaire. Forty-seven patients were asked to participate. RESULTS: Over 37 patients included, Wilcoxon-Mann-Whitney non parametric test confirmed agreement of the two ICIQ-UI-SF questionnaires with P=0.1792. Twenty-three patients were validated to the Minimult inventory with F scale<70. We analysed variability of the two global ICIQ-UI-SF score in regard with the validity scale using ROC analysis. We observed an AUC of 0.559 with sensitivity 78.6% and specificity 43.5%. No L score was above 70 demonstrating absence of lie. No personality disturbance was found in 9 cases. We observed six cases with a high hypochondric value, five with a high depressive value, and four with a high hysteric value. This neurotic triad was found in two cases. We noticed five cases with psychopathic deviance relative to antisocial behaviour while values of paranoia and hypomania were high in one case without any association of these personality aspects, which demonstrated absence of behavioural problem. Psychotic profile associating schizophrenia, paranoia, depression and hypomania was not found. We outlined in half of the valid population a significant high psycho-asthenic pattern. CONCLUSION: We conclude that a correlation between the personality inventory and the ICIQ-UI-SF is feasible. The comparative study demonstrate reliability of answers. Sincerity is established by the Minimult L scale. We confirm and precise literature information over clinical personality pattern of this population and observe relevant elements concerning the psycho-asthenic pattern which depicts an anxious personality with an important feeling of the problem. These elements permit to suspect that a personality disturbance may impact the physiopathology of the micturition. LEVEL OF EVIDENCE: 4.

A systematic review of the surgical treatment of large incisional hernia.

PURPOSE: Incisional hernia (IH) is one of the most frequent postoperative complications. Of all patients undergoing IH repair, a vast amount have a hernia which can be defined as a large incisional hernia (LIH). The aim of this study is to identify the preferred technique for LIH repair. METHODS: A systematic review of the literature was performed and studies describing patients with IH with a diameter of 10 cm or a surface of 100 cm2 or more were included. Recurrence hazards per year were calculated for all techniques using a generalized linear model. RESULTS: Fifty-five articles were included, containing 3,945 LIH repairs. Mesh reinforced techniques displayed better recurrence rates and hazards than techniques without mesh reinforcement. Of all the mesh techniques, sublay repair, sandwich technique with sublay mesh and aponeuroplasty with intraperitoneal mesh displayed the best results (recurrence rates of <3.6%, recurrence hazard <0.5% per year). Wound complications were frequent and most often seen after complex LIH repair. CONCLUSIONS: The use of mesh during LIH repair displayed the best recurrence rates and hazards. If possible mesh in sublay position should be used in cases of LIH repair.

The principles of abdominal wound closure.

BACKGROUND: Incisional hernia (IH) is a common complication of abdominal surgery. Its incidence has been reported as high as 39.9%. Many factors influence IH rates. Of these, surgical technique is the only factor directly controlled by the surgeon. There is much evidence in the literature on the optimal midline laparotomy closure technique. Despite the high level of evidence, this optimal closure technique has not met wide acceptance in the surgical community. In preparation of a clinical trial, the PRINCIPLES trial, a literature review was conducted to find the best evidence based technique for abdominal wall closure after midline laparotomy. METHODS: An Embase search was performed. Articles describing closure of the fascia after midline laparotomy by different suture techniques and/or suture materials were selected. RESULTS: Fifteen studies were identified, including five meta-analyses. Analysis of the literature showed significant lower IH rates with single layer closure, using a continuous technique with slowly absorbable suture material. No significant difference in IH incidence was found comparing slowly absorbable and non absorbable sutures. Furthermore, a suture length to wound length ratio of four or more and short stitch length significantly decreased IH rates. CONCLUSIONS: Careful analysis of the literature indicates that an evidenced based optimal midline laparotomy closure technique can be identified. This technique involves single layer closure with a running suture, using a slowly absorbable suture with a suture length to wound length ratio of four or more and a short stitch length. We adopt this technique as the PRINCIPLES technique.

Meta-analysis of glue versus sutured mesh fixation for Lichtenstein inguinal hernia repair.

BACKGROUND: Chronic pain remains a frequent complication after Lichtenstein inguinal hernia repair. As a consequence, mesh fixation using glue instead of sutures has become popular. This meta-analysis aimed to clarify which fixation technique is to be preferred for elective Lichtenstein inguinal hernia repair. METHODS: A meta-analysis was conducted according to the PRISMA guidelines. Articles published between January 1990 and April 2012 were searched for in MEDLINE, Embase and the Cochrane Library. Randomized controlled trials (RCTs) comparing glue and sutured mesh fixation in elective Lichtenstein repair for unilateral inguinal hernia were included. The quality of the RCTs and the potential risk of bias were assessed using the Cochrane risk of bias tool. RESULTS: Of 254 papers found in the initial search, a meta-analysis was conducted of seven RCTs comprising 1185 patients. With the use of glue mesh fixation, the duration of operation was shorter (mean difference -2·57 (95 per cent confidence interval (c.i.) -4·88 to -0·26) min; P = 0·03), patients had lower visual analogue scores for postoperative pain (mean difference -0·75 (-1·18 to -0·33); P = 0·001), early chronic pain occurred less often (risk ratio 0·52, 95 per cent c.i. 0·31 to 0·87; P = 0·01), and time to return to daily activities was shorter (mean difference -1·17 (-2·30 to -0·03) days; P = 0·04). The hernia recurrence rate did not differ significantly. CONCLUSION: Elective Lichtenstein repair for inguinal hernia using glue mesh fixation compared with sutures is faster and less painful, with comparable hernia recurrence rates.

Abdominal wall bulging after thoracic surgery, an underdiagnosed wound complication.

BACKGROUND: Complications after thoracic surgery have well been established, pain being the most prominent. Intercostal nerves are mixed type nerves combining motor and sensory functions. This notion is not consistent with the incidence of PTPS compared to the incidence of muscle paresis or paralysis. We would hypothesize that abdominal wall paresis or paralysis is underdiagnosed. METHODS: In our hospital, three patients developed abdominal wall paralysis after thoracic surgery and consequent nerve damage. Their cases are discussed, and a review of the literature was conducted concerning (intercostal) nerve damage on a cellular level, the anatomy of the intercostal nerve, prevention of intercostal nerve damage and surgical techniques. RESULTS: A cellular cascade known as Wallerian degeneration and regeneration determine whether a damaged nerve can function again. The recovery of the nerve is highly dependent on the correct function of activated Schwann cells and macrophages and is related to the amount of damage that has taken place. The anatomy of the intercostal nerve makes it susceptible to injury. Retractor placement during open thoracic surgery has shown to effect compression injury and induced mechanical deformation and damage. Given the known factors of pathophysiology and anatomy, a number of preventive measures have been tested to reduce intercostal nerve damage. Several techniques have been proposed, but the most used technique, the video-assisted thoracic surgery, has been the most effective in reducing nerve damage. CONCLUSION: Abdominal wall paralysis is an underdiagnosed complication after thoracic surgery. The amount of stress on the intercostal nerves could be reduced with less invasive techniques such as the VATS technique.

The impact of mandibular advancement on articulation, resonance and voice characteristics in Flemish speaking adults: a pilot study.

Bilateral saggital split osteotomy (BSSO) of the mandible is a frequently performed mandibular orthognathic procedure, used to resolve mandibular disharmonies. Literature review showed contradictory findings regarding the effect of the orthognathic surgery on speech characteristics. The purpose of the present study was to determine a detailed analysis of the articulation, resonance and voice characteristics after BSSO with mandibular advancement for the treatment of Class II malocclusions using objective and subjective assessment techniques (perceptual evaluations, Dysphonia Severity Index, nasalance scores) in eight subjects. The findings of the present study indicate that before and after BSSO with mandibular advancement three types of articulation disorders may predominate in the Flemish language: the incorrect production of the trill sound /r/ and the /s/ sound and devoicing of the /z/. After orthognathic surgery most patients showed an identical articulation pattern (normal or disturbed pattern) as in the presurgical condition. In this study the BSSO with mandibular advancement had no significant impact on the nasality characteristics and the nasalance values probably due to the competent velopharyngeal valving in the presurgical condition. And, as expected the vocal quality revealed no significant difference. The maxillofacial surgeon and the speech language pathologist must be aware of the persistency of these preoperative articulation errors in the postsurgical condition.

[Methodology of penile isotope imaging. Evaluation]. / Méthodologie du pénogramme isotopique. Mise au point.

AIMS: Duplex ultrasonography and pulsed doppler analysis or dynamic infusion cavernosometry and cavernosography are used for functional evaluation of penile arterial or venous dynamics during a pharmacological erection. The accuracy of the echographic investigations is correlated to the investigator experience. Cavernosometry and cavernosography are more invasive technique than the radioisotope erection penogram, which is a reproductive and reliable test. MATERIAL AND METHODS: We investigate 60 patients. Neurological, psychological and endocrinological etiology are excluded. The technique is described: thyroid is blocked by potassium perchlorate, bloodpool is labelled with Tc99m, a dynamic study is performed over 60 mn with intracavernous injection of PGE1 5g or Papaverine 30 mg at T10mn, ROIS are defined by computer processing, a phalogram curve is provided. RESULTS: This noninvasive test sorts out arteriogenic, venogenic and psychogenic impotence by a qualitative curve analysis. The quantitative parameters depending on numerous time consuming variables have proved to be of poor clinical use and non significant. We objectivate 20 psychogenic impotence, 27 arteriogenic impotence, 7 venous leakage and 6 mixed (arteriogenic and venogenic) impotence. Statistic evaluation of arteriogenic lesions comparative by doppler technique reveals a sensitivity of 83% and a specificity of 87%. The advantages of the test are; ambulatory, objective, noninvasive and reliable investigation. In the same time, "qualitative" data evaluates the response to a pharmacological induced erection. CONCLUSIONS: The radioisotope erection penogram is a noninvasive, reproductive and reliable screening test for vasculogenic impotence.

Identification and isolation of the indole-3-pyruvate decarboxylase gene from Azospirillum brasilense Sp7: sequencing and functional analysis of the gene locus.

The root-associated bacterium Azospirillum brasilense Sp7 produces the growth-stimulating phytohormone indole-3-acetic acid (= IAA) via the indole-3-pyruvate pathway. The DNA region containing ipdC, the structural gene for indole-3-pyruvate decarboxylase, was identified in a cosmid gene library of strain Sp7 by hybridization and has been sequenced. Upstream of the gene, two other ORF homologous to gltX and cysS were sequenced that are transcribed in the opposite direction. A functional analysis of the cloned ipdC region has been performed. To test the expression of the gene, a lacZ-Km cartridge was introduced into the gene. By this construct, tryptophan-dependent stimulation of gene expression in A. brasilense Sp7 was observed. Evidences for the existence of another copy of the ipdC gene in the Azospirillum genome are also reported.

[Therapeutic strategy for Wunderlich syndrome]. / Stratégie thérapeutique du syndrome de Wunderlich.

Spontaneous retroperitoneal hemorrhage from the kidney was first described in 1700 by Bonet. Wunderlich gave his name to this rare syndrome in 1856. Up to now, 250 cases are reported. This disease entity is associated with an underlying pathology, which may be a benign tumor such an angiomyolipoma or a malignant tumor such renal cell carcinoma. We report two cases whose presenting features were those of this syndrome. We discuss the radiological characteristics including intravenous pyelography, renal angiography, computerized tomography and magnetic resonance imaging. Preoperative diagnosis is corroborated by surgical exploration and radical nephrectomy. We conclude in recommending computerized tomography as the examination of choice.

Precocious onset of spermatogenesis in juvenile carp (Cyprinus carpio L., Teleostei) following treatment with low doses of L-thyroxine.

Two strains of carp (Cyprinus carpio L.), a heterogenic and an all male isogeneic, were used as experimental models to assess the effects of low doses of L-thyroxine (T4) on testicular development in juvenile fish. In four experiments (two with each strain) precocious onset of spermatogenesis was induced following exposure to 15 micrograms T4 l-1, but not to 8 micrograms or 30 micrograms T4 l-1. No significant increase in body weight and testis diameter (week 16 excepted) or numbers of primary spermatogonia was observed. Total T4, measured in the isogeneic strain, increased significantly in the serum of experimental specimens within two weeks after the onset of exposure, evidencing a readily absorption of the exogeneous T4. The contents of free T4 and total triiodothyronine (T3) in the serum were measured too, showing different levels in the two experiments, as also was observed with total T4. The content of free T3, which is formed in the cells of peripheral tissues by deiodination of T4 and which supposedly exerted the observed effect on spermatogenesis, could not be determined by the used standard Amerlite assays. It is hypothesized that T3 enhances in males the activity of gonadotropic hormones, which in turn will stimulate steroid production, similar to findings in females.

[Contribution of Abrams Griffiths' graphic charts in the analysis of urinary urgency in women]. / Apport de l'expression graphique selon Abrams Griffiths dans l'analyse de l'instantané mictionnel chez la femme.

The simplest way to obtain a meaningful result about detrusor pressure and urethral function is to have the plot superimposed on the Abrams-Griffiths nomogram. This concept is used to obtain information related to subvesical obstruction due to prostatic hypertrophy in male. We show herein that this type of analysis allows an objective estimate of pressure-flow relationships and permit simplification in analyzing micturition in women.

[Liposarcoma of the spermatic cord]. / A propos d'un cas de liposarcome du cordon spermatique.

The liposarcoma is mainly located in the retroperitoneum and rarely involves the spermatic cord. Dissemination occurs more often via haematogenous way than by lymphatic way. The incidence of local recurrence is higher than distant metastases. The treatment of choice is the wide excision. Adjuvant radiotherapy is recommended in the well differentiated and myxoid type of tumors if the local control during excision is not complete or wide enough. Benefit of chemotherapy is still controversial and limited. Case report of a stage 1 liposarcoma of the spermatic cord, four years after excision of a large lipoma during a hernia repair. The treatment consisted in radical excision of this liposarcoma without any adjuvant therapy. Follow-up of 30 months without recurrence.