Accessory cavitated uterine mass: MRI features and surgical correlations of a rare but under-recognised entity

OBJECTIVES

To describe MRI features of accessory cavitated uterine mass (ACUM) with surgical correlations.

METHODS

Eleven young women with an ACUM at pathology underwent preoperative pelvic MRI. Two experienced radiologists retrospectively analysed MR images in consensus to determine the lesion location within the uterus, its size, morphology (shape and boundaries), and structure reporting the signal and enhancement of its different parts compared to myometrium. The presence of an associated urogenital malformation or other gynaecological anomaly was reported. MRI features were correlated with surgical findings.

RESULTS

All 11 lesions were well correlated with surgical findings, lateralised (seven were left-sided), and located under the horn and the round ligament insertion. Nine were located within the external myometrium, bulging into the broad ligament. Two were extrauterine, entirely located within the broad ligament. On MRI, the mean size was 28 mm (range 17-60 mm). Nine lesions were round-shaped, two were oval; all had regular boundaries. At surgery, the ACUM were not encapsulated but were possible to enucleate. On MRI, all lesions were well defined and showed a central haemorrhagic cavity surrounded by a regular ring (mean thickness, 5 mm) which had the same signal compared to the junctional zone. ACUM was isolated in all women, without urogenital malformation, adenomyosis or deep endometriosis.

CONCLUSIONS

On MRI, ACUM was an isolated round accessory cavitated functional non-communicating horn-like aspect in an otherwise normal uterus. MRI may facilitate timely diagnosis and appropriate curative fertility-sparing laparoscopic resection.

KEY POINTS

• ACUM is rare, with delayed diagnosis in young women with severe dysmenorrhoea. Pelvic MRI facilitates timely diagnosis and appropriate curative fertility-sparing laparoscopic resection. • Quasi-systematically located under the uterine round ligament insertion, ACUM may be intramyometrial and/or in the broad ligament. • On MRI ACUM resemble a non-communicating functional accessory horn within a normal uterus; the mass, most often round-shaped, had a central haemorrhagic cavity surrounded by a regular ring which had the same low signal compared to the uterine junctional zone.

[Hysteroscopic septoplasty: after miscarriages?]

OBJECTIVE

To assess reproductive outcome of women affected by septate uterus after surgical correction.

PATIENTS AND METHODS

It is a retrospective study. The setting is a French university hospital. Surgery was performed on 66 patients between 2000 and 2010. Hysteroscopic metroplasty was performed in every group once the diagnosis was made. There were two groups: 35 patients affected by septate uterus had past history of miscarriages, preterm and term deliveries. Thirty-six patients had never been pregnant.

RESULTS

In the group of 35 patients with a previous obstetric history, the rate of miscarriages was 57.1% before surgery and 10% after surgery. There was a significant gain of live birth ratio of 55% among women being pregnant after surgery compared to women being pregnant before surgery. For patients with no pregnancy before surgery, obstetrical results are the following ones: miscarriages 25.9%, preterm deliveries 11% and term deliveries 59.3%.

DISCUSSION AND CONCLUSION

Hysteroscopic septoplasty is an easy technique with few complications in our study. Hysteroscopic septoplasty is strongly recommended after recurrent miscarriages or premature deliveries. We use to propose surgery to every patient affected by septate uterus, even if they have never been pregnant.

Ultrasonography and MRI features of the Mayer-Rokitansky-Küster-Hauser syndrome

Although Mayer-Rokitansky-Küster-Hauser syndrome is a rare condition with a reported incidence of 1/4500 female live births, it represents the second most common cause of primary amenorrhea and has psychologically devastating consequences. The radiologist plays a pivotal role in both making the accurate initial diagnosis of this condition and assessing findings that may contribute to treatment planning. The purpose of this article is to provide an overview of the capabilities of ultrasound and magnetic resonance imaging (MRI) for the diagnosis and management of this syndrome with emphasis on the relevant clinical and surgical findings and to describe potential associated abnormalities and differential diagnosis.

[Hysteroscopic myomectomy using bipolar energy: a gold standard?]

In recent years, hysteroscopic resection has become the treatment of choice for submucous fibroids. Technological advances enabled the use of bipolar resectoscopes, in the same way as new bipolar instruments used in laparoscopy or open surgery. Bipolar systems would be expected to eliminate the risks of hyponatremia and electrical burns. In evaluation studies, bipolar energy used in operative hysteroscopy is as effective in comparison with the unipolar system. However, no clinical study has yet shown increased reliability of bipolar resection to consider their use as a gold standard. Outpatient operative hysteroscopy is now developing rapidly with the introduction of bipolar energy and small-diameter endoscopes. Although the financial impact is unknown, It allows time saving with maximal safety, avoiding cervical dilatation and anesthetic procedures.

Features of pigmented vulval lesions on dermoscopy

BACKGROUND

The dermoscopic criteria for benign and malignant lesions on the vulva are not well established due to the lack of large series of such lesions. Melanoma should always be included in the differential diagnosis of pigmented lesions on the vulva especially when they are wide, or of recent onset. Elsewhere on the skin dermoscopy plays an important role in the selection of suspicious pigmented lesions, as well as in the selection of the best site to perform the biopsy.

OBJECTIVES

To analyse the dermoscopic patterns observed in pigmented lesions of the vulva.

METHODS

We analysed a nonselected consecutive series of 68 histopathologically proven cases comprising five melanomas, 16 naevi, 20 lentigos, 12 benign vulval melanoses, 11 cases of postinflammatory pigmentation, three pigmented cases of usual vulval intraepithelial neoplasia (VIN) and one seborrhoeic keratosis seen at our institution. The dermoscope was covered by translucent disposable food wrap and/or antibacterial gel to prevent possible transmission of infections. Descriptive statistics were performed using multiple correspondence analysis.

RESULTS

The parallel (37%), ring-like (9%), homogeneous (22%), globular-like (13%) and reticular-like (6%) patterns were observed on benign lesions (naevi, lentigo, vulval melanosis and postinflammatory pigmentation). The cerebriform pattern (6%) was observed only on VIN and seborrhoeic keratosis. The multicomponent pattern (6%) was associated with melanoma (60%). In cases of melanoma we also occasionally observed an irregular pattern, a whitish or blue-whitish veil, irregularly distributed dots and globules and atypical vascular pattern. Using multiple correspondence analysis, we designed a new algorithm for the early detection of vulval melanomas.

CONCLUSIONS

Dermoscopy can play a role in the noninvasive classification of vulval melanosis. However, further studies of larger collaborative series are needed to validate our vulval melanoma diagnostic algorithm. VIN and seborrhoeic keratosis share the same dermoscopic features and biopsy should be considered for seborrhoeic-like keratosis. In case of doubt pathological examination of a biopsy remains mandatory.

[Review: Repetitive hydatidiform moles]

Repetitive moles are rare. They are either sporadic or familial, with or without consanguinity. Some of them can be explained by a NLRP7 mutation, which causes genomic parental imprinting alteration, with a preferential paternal phenotypic expression. Currently, no effective therapeutic solution has been developed. Among the 1687 patients declared to the French Trophoblastic Disease Reference Center, 13 presented at least two hydatidiform moles, thus less than 1% of the patients. A mutation of the NLRP7 gene was shown in six of 12 tested patients (50%) among whom three presented a homozygous mutation and three a heterozygous mutation. For an affected patient, type of mole can indifferently be a complete hydatidiform mole or a partial hydatidiform mole. We describe these cases and compare them to those already published.

Predictive values of hCG clearance for risk of methotrexate resistance in low-risk gestational trophoblastic neoplasias

BACKGROUND

Early identification of patients at high risk for chemoresistance among those treated with methotrexate (MTX) for low-risk gestational trophoblastic neoplasia (GTN) is needed. We modeled human chorionic gonadotropin (hCG) decline during MTX therapy using a kinetic population approach to calculate individual hCG clearance (CL(hCG)) and assessed the predictive value of CL(hCG) for MTX resistance.

PATIENTS AND METHODS

A total of 154 patients with low-risk GTN treated with 8-day MTX regimen were retrospectively studied. NONMEM was used to model hCG decrease equations between day 0 and day 40 of chemotherapy. Receiver operating characteristic curve analysis defined the best CL(hCG) threshold. Univariate/multivariate survival analyses determined the predictive value of CL(hCG) and compared it with published predictive factors.

RESULTS

A monoexponential equation best modeled hCG decrease: hCG(t) = 3900 x e(-0.149 x t). Median CL(hCG) was 0.57 l/day (quartiles: 0.37-0.74). Only choriocarcinoma pathology [yes versus no: hazard ratio (HR) = 6.01; 95% confidence interval (CI) 2.2-16.6; P < 0.001] and unfavorable CL(hCG) quartile (< or =0.37 versus >0.37 l/day: HR = 6.75; 95% CI 2.7-16.8; P < 0.001) were significant independent predictive factors of MTX resistance risk.

CONCLUSION

In the second largest cohort of low-risk GTN patients reported to date, choriocarcinoma pathology and CL(hCG) < or =0.37 l/day were major independent predictive factors for MTX resistance risk.

[Vulvoperineal reconstruction after extended radical vulvectomy: two reconstructive procedures]

Poor perineal healing is often a major complication of extended radical vulvectomy in case of vulvar carcinoma. Procedures of vulvoperineal reconstruction require several criteria of quality for their use. The chosen technique should be: (1) reliable; (2) reproducible; (3) with minimal morbidity; (4) not much invasive with good anatomical and functional results. We describe two procedures of perineal reconstruction that correspond to the previous criteria: a local fasciocutaneous flap with lateral transposition and a regional musculocutaneous flap using the gluteus maximus muscle.

[Vaginal hysterectomy using electrofusion: a study of 96 cases]

OBJECTIVE

To compare ligature by electrofusion versus sutures in the practice of vaginal hysterectomy.

STUDY DESIGN

This is a retrospective study on 96 patients completed over a period of 47 months. Patients were allocated into two groups: the electrofusion "suture-free" group (n=54) and the "suture" control group (n=42). Designed-end points were operating time, postoperative pain, duration of postoperative hospitalization and perioperative complications.

RESULTS

In the electrofusion group, the operating time was significantly reduced (51.3+/-22.6 min versus 67.6+/-20.1 min) as well as the reported postoperative pain (based on the visual analog scale - VAS) (1.9+/-2.0 versus 3.5+/-2.3). The average morphine consumption rate and the timing of postoperative morphine administration were lower in the electrofusion group (22.4+/-31.0mg versus 45.4+/-51.3 mg and 22.4+/-13.4 h versus 29.4+/-18.8 h, respectively). Moreover, in the electrofusion group there was less need for additional analgesics (1.9+/-2.0 versus 3.5+/-2.3) and the hospital-stay was shorter (4.2+/-1.3 days versus 5.0+/-1.0 days). There was no significant difference between the two groups in regard to perioperative complications.

CONCLUSION

The use of electrofusion in vaginal hysterectomy appears to be a reliable ligation technique which reduces significantly the operating time, the postoperative pain and the length of postoperative hospitalization.

[Feto-maternal metabolism in human normal pregnancies: study of 73 cases]

From 73 normal pregnancies of gestational age between 17 and 41 weeks of gestation (WG), the concentrations of glucose, pyruvate and lactate, free fatty acids, ketone bodies (aceto-acetate and beta-hydroxybutyrate) and cholesterol were assessed on maternal venous blood (MVB) and umbilical venous blood (UVB), sampled by cordocentesis. The objective of this work was to study feto-maternal metabolism, as well as nutritional exchange between maternal blood and fetal blood during the second and third trimesters of pregnancy. Maternal and fetal glycemias, as well as maternal-fetal glucose concentration gradient, were found stable during the studied gestational period; maternal glucose is always higher than fetal glucose, with a mean concentration delta of 0.69+/-0.34 mmol/L. Maternal lactate level (1.26+/-0.38 mmol/L) is lower than fetal lactate level (1.48+/-0.46 mmol/L), whereas maternal blood pyruvate concentration (0.042+/-0.020 mmol/L) is higher than fetal blood pyruvate concentration (0.025+/-0.010 mmol/L). Consequently, mean lactate / pyruvate ratio is found twice lower in maternal blood (31.77+/-9.89) than in fetal blood (64.10+/-17.12). Free fatty acids concentration is approximately three times higher in maternal blood than in fetal blood (respectively 0.435+/-0.247 mmol/L and 0.125+/-0.046 mmol/L). Maternal venous aceto-acetate (0.051+/-0.042 mmol/L) and beta-hydroxybutyrate (0.232+/-0.270 mmol/L) concentrations are significantly lower than those in UVB (respectively 0.111+/-0.058 and 0.324+/-0.246 mmol/L) and the beta-hydroxybutyrate/aceto-acetate ratio is on average 1.7 times higher in MVB (4.75+/-2.5) than in UVB (2.82+/-1.18). Cholesterol concentration is significantly higher in maternal blood (6.26+/-1.40 mmol/L) than in fetal blood (1.66+/-0.34 mmol/L). Our results show the characteristics of oxidative metabolism of the fetus compared with that of the adult. Blood concentration in energy substrates, measured with glucose and free fatty acids levels, is low in UVB and suggests increased energy needs of the growing fetus. Mean high concentrations in aceto-acetate and beta-hydroxybutyrate in UVB, indicate probably fetal ketogenesis. UVB low cholesterolemia suggests high cholesterol consumption in the fetal compartment for cellular membrane synthesis and steroid biosynthesis.

Évaluation de la prise en charge des tumeurs trophoblastiques gestationnelles enregistrées au Centre de référence des maladies trophoblastiques de Lyon de 1999 à 2005

OBJECTIVES

The aim of this study was both to analyse if gestational trophoblastic neoplasia (GTN) registered to the French Trophoblastic Disease Reference Center (TDRC) in Lyon (France) were managed according to the FIGO criteria for diagnosis of GTN and if chemotherapy was adapted to the 2000 FIGO prognostic scoring system.

PATIENTS AND METHODS

Retrospective, descriptive analysis of 167 GTN registered to GTC of Lyon between 1999 and 2005.

RESULTS

On the one hand, 66% of women (104/158) had a diagnosis of GTN according to FIGO criteria. One third (n=54) of the patients therefore had a premature or erroneous diagnosis of a tumor, when the treatment started. No supporting element of this premature diagnosis has been found out for 26 patients. The identification of lung and vaginal metastasis and histological diagnosis of invasive mole appeared as the most mentioned inappropriate criteria for diagnosis. On the other hand, chemotherapy was adapted to 2000 FIGO scoring in 91, 5% of cases. Twelve low risk GTN were treated with polychemotherapy and two high risk GTN were treated with monochemotherapy. Moreover 29% of the patients received a non adequate treatment due to deviations from the recommended protocol.

DISCUSSION AND CONCLUSION

Non respect of FIGO criteria for the diagnosis of GTN can lead to erroneous diagnosis of tumors. Identification of lung or vaginal metastasis or diagnosis of invasive mole should not automatically justify the diagnosis of gestational trophoblastic neoplasia if the decrease in HCG occurs properly. Respect of FIGO criteria for the diagnosis of GTN and adaptation of chemotherapy to 2000 FIGO scoring are necessary to avoid inadequate treatment of gestational trophoblastic neoplasia.

[Biochemical profile of fetal blood sampled by cordocentesis in 35 pregnancies complicated by growth retardation]

AIM OF THE STUDY

Intra-uterine growth retardation (IUGR) is a frequent pathology in obstetrics characterized by high heterogeneity. Fetal smallness is sometimes constitutional, but can also be accompanied by fetal distress and vital risks for the infant. In 35 pregnancies complicated by IUGR of different etiologies, we measured on fetal blood obtained by cordocentesis, biochemical variables characteristic of the fetuses' respiratory and metabolic status. The aim of the study was to identify the discriminative biological alterations, related to growth retardation and fetal distress.

PATIENTS AND METHODS

The studied population includes 27 cases of severe IUGR, of gestational age 30,2+/-4,6 weeks of gestation (WG) (divided into 20 cases of isolated IUGR and 7 cases of IUGR associated with malformative syndrome), as well as 8 cases of moderate IUGR, of gestational age 26+/-4,5 WG; all fetuses had normal karyotypes. A group of 73 normal fetuses, of gestational age 26,3+/-5,7 WG, constituted a reference population. PH, pCO(2), bicarbonate concentration, pO(2) and SaO(2), as well as glucose, pyruvate, lactate, free fatty acids, aceto-acetate, beta-hydroxybutyrate and cholesterol concentrations were measured on umbilical venous blood (UVB).

RESULTS

In case of severe but isolated growth retardation, UVB analysis showed the frequency of acid-base and gasometric disturbances: acidemia and hypoxemia (65% of cases), hypercapnia (60% of cases). Metabolic abnormalities were shown: decrease in glycemia (35% of cases), increase in pyruvatemia and lactatemia (40% of cases), increased free fatty acids serum concentration; a diminution of umbilical venous cholesterol level, the most frequent abnormality, can be seen in 70% of fetuses. In case of severe IUGR associated with malformative syndrome, UVB acid-base and metabolic changes were rarely seen; however, UVB cholesterol level is low in some cases. In case of growth retardation classified as moderate, modifications are relatively not frequent and essentially gasometric.

CONCLUSION

In about 60% of cases of severe and isolated IUGR, there is a risk of fetal distress, related to an alteration of the transplacental transfer of respiratory gases and nutritional substrates; chronic fetal malnutrition can be involved, with an impact on the growth of the fetus. In case of IUGR associated with malformative syndrome, fetal smallness is probably a result of intrinsic fetal damage, without nutritional origin.

Prognosis of early-onset breast cancer based on BRCA1/2 mutation status in a French population-based cohort

591

Background: The debate concerning poorer survival for patients with breast cancer (BC) carrying a BRCA1 germline mutation is unresolved, and requires additional data from population-based studies. Methods: We followed 232 women with invasive BC under age 46, ascertained prospectively through a French population-based BC registry, and tested for BRCA1/2 mutations (median follow-up: 82 months). We compared tumour characteristics and survival rates between 21 BRCA1/2 deleterious mutation carriers and 211 non-carriers. Results: As compared to sporadic tumours, BRCA1/2 tumours showed higher grade (p = 0.02), fewer ductal carcinoma in situ (p = 0.02), more frequent medullary histology (p = 0.02), more frequent negative oestrogen and progesterone receptors (p = 0.001 each). At five years, BC-specific survival, metastasis-free survival, ipsilateral recurrence-free survival and contralateral BC-free survival rates for BRCA1/2 mutation carriers were 95.0%, 94.7%, 100% and 90.0% respectively, compared with 89.6%, 78.2%, 88.8% and 94.4% respectively, for non-carriers (not significant). Rates for women carrying only a BRCA1 mutation were 93.3%, 93.3%, 100%, 86.7%, respectively. 76% of BRCA1/2 carriers received chemotherapy. Conclusions: Despite unfavourable tumour features, we found no evidence for poorer short-term survival in BRCA1 mutation carriers compared to non-carriers in this prospective population-based cohort. The high rate of BRCA1 carriers who received chemotherapy for their BC should question the positive impact of this treatment, as suggested by preclinical studies showing increased chemosensitivity of BRCA1-associated tumours.

No significant financial relationships to disclose.

Induction of transplantation tolerance in humans using fetal cell transplants

When engrafted with donor stem cells and lymphoid cells, patients develop transplantation tolerance to donor antigens. We analyzed the mechanism of tolerance induction in immunoincompetent recipients whose immunity has been reconstituted by transplantation of mismatched stem cells. Seven infants or human fetuses received fetal liver transplants as a treatment for severe combined immunodeficiency disease. After reconstitution of immunity by lymphocytes developed from donor stem cells, T-cell clones were produced and analyzed. Because donors and recipients were HLA mismatched, it was easy to demonstrate the donor origin of the T-cell clones. These clones were shown to have developed tolerance to histocompatibility antigens of the stem cell donor via a process of clonal deletion (probably as a result of contact with donor-derived macrophages and dendritic cells). They were also tolerant to histocompatibility antigens of the host but through a different mechanism: many clones recognized these antigens but had no detrimental effect on the target cells exhibiting host antigens, either in vitro or in vivo. Clonal anergy was therefore the cause of this tolerance to host determinants, resulting in a lack of graft-versus-host disease and of autoimmunity. The contact between developing T cells of donor origin and host epithelial cells within the host thymus may explain this colonal anergy. It should be noted that all patients had high serum levels of interleukin-10, which might have contributed to the persistent engraftment and tolerance.

[Sensitivity and specificity of two methods used to identify incident breast cancer in specialized units using claims databases]

BACKGROUND

Hospital claims databases from acute care units are available nationwide and contain most patients at the beginning of their cancer. The goal is to define the ability of these databases to provide a number of incident breast cancer cases using identification methods. Two identification methods were assessed in three specialized sections of a teaching hospital.

METHODS

The first method identified women who had at least one stay with a principal diagnosis of breast cancer. The second, which is more restrictive, identified women who had at least one stay with a principal diagnosis of breast cancer and a breast cancer-specific surgical treatment code. Both methods were applied to 4588 women 20 Years of age or older hospitalized in three specialized sections of the Hospices Civils de Lyon in 2000. To categorize these women in two groups, incident breast cancer cases or non-incident breast cancer cases, 150 women were randomized in each of two groups, one for incident breast cancer cases and one for non-incident breast cancer cases. Their medical records were used as references.

RESULTS

Sensitivity, specificity and their credibility intervals were respectively 99.4% (84-99.9) and 91.7% (90.3-93.3) for the first method and 93.8% (76.2-98.7) and 97.3% (96.1-98) for the second. Among women wrongly identified with an incident breast cancer in 2000, 75.4% (43/57) had a breast cancer that was not incident that Year with the first method, compared to 96% (24/25) with the second. Among these women wrongly identified with an incident breast cancer, coding errors of the principal diagnosis were found for 24.6% (14/57) of patients with the first method and for 4% (1/25) with the second. Their correction led to 99.2% (86.5-99.9) sensitivity and 92.9% (91.4-94.6) specificity for the first method and to 94.2% (76.5-98.7) sensitivity and 97.3% (96.2-98.1) specificity for the second.

CONCLUSIONS

The second method using cancer-specific surgical codes appeared more specific with a slight loss in sensitivity. The use of identification methods to assess the number of incident cancer cases still have to be defined.

Color Doppler energy prediction of malignancy in adnexal masses using logistic regression models

OBJECTIVE

The aim of this study was to assess the usefulness of color Doppler energy in the preoperative diagnosis of ovarian malignancy using multivariate logistic regression analysis.

METHODS

One hundred and thirty adnexal masses were studied with transvaginal B-mode, color energy, and pulsed Doppler ultrasonography before surgery in order to develop a model that could be used to determine malignancy. Each ultrasonographic variable (tumor size, wall thickness, septal structure, echogenicity, papillary projection, density (solid or not)) was included individually or combined together as part of the Sassone ultrasound score. Intratumoral blood flow velocity waveforms were obtained to determine pulsatility index and resistance index and a more subjective parameter, location of tumor vascularity, was also assessed. Menopausal status and serum CA 125 levels were also entered as categorical variables. Sonographic parameters were entered alone, then associated with menopausal status and CA 125 serum levels, and finally with Doppler energy measurements. Our model was then validated in a group of 68 adnexal masses and compared to the model of Alcazar.

RESULTS

Eighteen adnexal masses (13.8%) were malignant or of low malignant potential. Multivariate analysis showed that papillary projection of the tumor wall, cyst with solid parts, resistance index with a cut-off value of 0.53, CA 125, and central blood flow location, were the only factors to be independent predictors of malignancy. Menopausal status was not an independent factor. For the final model including the Doppler energy parameter the best sensitivity and specificity were 83% and 93%, respectively, at a cut-off value of 10% probability of malignancy compared to 83% and 87% for the morphological variables alone. Validation of the model showed its diagnostic performance to be as good as that reported in the original population and better than the model of Alcazar.

CONCLUSION

Sonographic analysis of adnexal masses including color Doppler energy shows the best predictive properties according to histological diagnosis, and improves preoperative diagnosis of malignancy.

[Intrauterine devices in general practice: a prospective study of 300 insertions]

OBJECTIVE

To assess the effectiveness of management practices of copper intrauterine devices (IUD) in general medicine.

MATERIAL

and methods. A prospective study was conducted over a four-year period. Thirty-four experimented and volunteer general practitioners inserted 300 IUDs. Two hundred and ninety-seven patients were evaluated. A 375-mg copper IUD was used. Results are presented by 12-month device survival, cumulative discontinuation, and event rates per hundred women.

RESULTS

At the end of the study 19.8% (n=59) of the women were lost to follow-up. Exposure time to IUD was 9245 cycles. Mean exposure time was 3917 cycles. Discontinuation rates for IUD were 82%, 67%, and 31% at 12, 36, and 48 months respectively. Renewal rate for this contraceptive device was 31.5%. Results confirmed that IUD were highly effective in this population: Pearl index 0.51% with four pregnancies. A very low expulsion rate (1.68%) and good tolerance (cumulative removal rate for medical reasons at 60 months=6.1%) were observed. At the end of the study, 61.3% of the women included had no complaints and had their IUD removed for desired pregnancy, replacement or personal reasons.

CONCLUSIONS

Our findings are similar to reports in the literature; there was no evidence of differences between general practitioners and gynecologists. IUDs inserted by experimented general practitioners are safe and should continue to be offered as a contraceptive option for properly selected women. These findings suggest that specific training on contraceptives should be provided to interested general practitioners

Functional ovarian cysts and the need to remove them

OBJECTIVE

To review the need for the removal of functional ovarian cysts.

MATERIALS AND METHODS

Over a 5-year period, between July 1994 and June 1999, all functional ovarian cysts files were reviewed in order to determine the main surgical indication.

RESULTS

Thirty-four functional ovarian cysts (11.45%) were removed during that period. In 14 cases, the surgical operation was considered justified. In 32 cases, the cysts were not organic as supposed to be and had no reason to be removed.

DISCUSSION

Reported functional ovarian cyst removal rates range from 15 to 30%. Present exploration means (particularly ultrasound-guided needle aspiration) does not permit to discriminate functional from organic cysts in more than 70% of the cases.

CONCLUSION

It is impossible to reduce functional cyst removal rate to 0% but we should all evaluate our activity yearly and be able to limit this rate to less than 30%.

Transvaginal cervicoisthmic cerclage as an alternative to the transabdominal technique

OBJECTIVES

To analyse the foetal outcome after transvaginal cervicoisthmic cerclage, to determine whether it is a valid alternative to the reference transabdominal technique.

STUDY DESIGN

Description of the vaginal operative technique, retrospective review of 20 cervicoisthmic cerclage patients from 1990 to 2000.

RESULTS

In the curative group of women with a history of late pregnancy losses or premature deliveries and usually previous failed classical cervical cerclage, the foetal survival rate improved from 18% before cerclage to 79% after cerclage. No operative complications were reported. In the prophylactic group, typically characterised by the absence of the cervix as a consequence of surgery for invasive cervical cancers, the foetal survival rate was 83% after cerclage.

CONCLUSIONS

The transvaginal cervicoisthmic cerclage allows a high foetal survival rate without complications in highly selected patients with poor obstetrical history. Because of its simplicity, this technique should replace the transabdominal route for surgeons experienced in vaginal surgery.

[Operative technique for assumed benign ovarian cysts]

Assumed benign ovarian cysts are best treated by laparoscopy rather than laparotomy (NP1). A peritoneal sampling for cytology should always be performed first (NP5). Frozen section diagnosis for suspicion of malignancy requires specific conditions (NP5). Laparoscopic treatment of macroscopically functional cysts can not be limited to needle aspiration (NP5). There is not enough evidence to privilege cystectomy after needle aspiration over attempt to achieve enucleation of the cyst; however, uncontrolled rupture of the cyst is the risk associated with the latter procedure (NP5). Authors usually recommend extraction of the cyst through a bag (NP5). There is not enough evidence for or against ovarian suture. Benefits of adhesion barriers after ovarian cystectomy has to be proved. The majority of the authors perform a bilateral oophorectomy in case of unilateral postmenopausal cyst (NP5). As much parenchyma as possible should be preserved in case of large ovarian cysts. For women with small controlateral dermoid cysts, the validity of surgical abstention is not established. Conservative surgery is the rule in case of premenopausal mucinous cysts.

[Methods for laparoscopy: open laparoscopy or closed laparoscopy? Attitude of the French Central University Hospital]

Standard technique of insufflation of the pneumoperitoneum includes the use of the Veress needle followed by the blind insertion of the umbilical trocar. To avoid blind trocar insertion, numerous techniques for the creation of the pneumoperitoneum have been reported: open-laparoscopy and micro-laparoscopy are the two major alternative methods used in France. The aim of this study was to determine the incidence of open-laparoscopy in the French departments of Gynecology of the University Hospitals. With this purpose, we send to each chief of the department of Gynecology in a University Hospital a simple questionnaire about the methods used in his division for the creation of pneumoperitoneum. Sixty-three chiefs of department have answered to the questionnaire. Thirteen (21%) answered they only used conventional technique. Ten (16%) departments perfonned always open-laparoscopy, and 40 University Hospital mostly used conventional technique combined sometimes when the initial procedure of insufflation failed or seems to be too dangerous (Obesity, previous laparotomy...). Five surgeons used a lateral rather than umbilical insertion for the openlaparoscopy in case of previous laparatomy. Fifteen departments used micro-laparoscopy since 1995, and mostly since 1998. We conclude that no simple technique can claim to be overwhelmingly superior. It seems tous dangerous to impose or to condemn any methods. Keeping the choice of the technique, learning security and organizing the survey of our results remain our recommendations for the approaches of abdominal entry for laparoscopy.

Planned vaginal delivery versus elective caesarean section in singleton term breech presentation: a study of 1116 cases

OBJECTIVE

To compare neonatal and maternal morbidity and mortality between planned vaginal delivery and elective cesarean section for singleton term breech presentation.

STUDY DESIGN

We studied retrospectively all deliveries of singleton breech presentations at term in the public Hospitals of Lyon between 1 January 1991 and 31 December 1995. To take only the effect of delivery on the fetus into account, we eliminated high risk pregnancies and fetal malformations. Fetal parameters were corrected perinatal mortality, Apgar score<7 at 1 and 5 min, umbilical cord arterial pH<7.15, neurological disorders, trauma and need for neonatal intensive care. Maternal parameters were mild, moderate and severe complications.

RESULTS

Of the 1116 breech presentations, 702 (62.9%) underwent an elective caesarean section and 414 (37.1%) a planned vaginal delivery. In the latter group, 342 (30.6%) had a vaginal delivery and 72 (6.5%) a non-elective caesarean section. Infants for whom the vaginal route was planned were at higher risk of mortality and morbidity. There were 2 deaths in this group and none in the elective caesarean section group and all fetal parameters were poorer: more Apgar<7 at 5 min (RR: relative risk=3.05; 1.03-9.05), arterial pH<7.15 (RR=1.64; 1.11-2.43), intubations (RR=7.35; 2.10-25.6), neurological disorders, trauma (RR=4.24; 1.66-10.8), transfer to intensive care units (RR=3.23; 1.57-6.64). The overall maternal morbidity was lower in the planned vaginal delivery group (RR=0.65; 0.44-0.94) but this was only because of less mild complications. The moderate and severe complications were the same in the two groups (RR=0.97; 0.59-1.57).

CONCLUSIONS

Planned vaginal delivery in singleton term breech presentation increases the risk of death and of neonatal complications. Elective caesarean section increases the risk of only mild maternal complications. For these reasons, elective caesarean section should be preferred for singleton term breech presentations.

[Laparoscopic retropubic colposuspension (Burch procedure). Techniques and continence results]

INTRODUCTION

Laparoscopy allows to perform Burch colposuspension in case of genuine urinary stress incontinence but this approach must not lead to reduced success rates.

OBJECTIVE

The aim of this study was to describe laparoscopic Burch techniques and evaluate urinary continence and satisfaction rates.

MATERIALS AND METHODS

Clinical and urodynamic data were reviewed for 48 consecutive patients operated on from May 1993 to June 1999. The methods for entering the space of Retzius and performing the colposuspension were analyzed. The continence and satisfaction rates were evaluated with a questionnaire.

RESULTS

The operative technique we are now using is the extraperitoneal approach with an umbilical trocar site. A non-absorbable mesh is fixed to the Cooper's ligament and to the vaginal fascia. With a mean follow-up of 41 months, the satisfaction rate is 76.8% with a cure rate of 37.3% and an improvement rate of 41.8%.

CONCLUSION

Long term results with laparoscopic Burch colposuspension are relatively good but a bit lower than those published with traditional open technique. The effects of the learning curve with an evolving technique are to be considered when analyzing the results.

[A plea for the creation of trophoblastic disease reference centers in France]

Gestational trophoblastic diseases include partial and complete molar pregnancies together with trophoblastic tumors, namely invasive mole, choriocarcinoma and placental site trophoblastic tumor. Important advances continue to occur in both our understanding and management of these diseases. The general guidelines we display here are intended to standardize the essential current management of trophoblastic diseases and justify the creation of a reference center in France. The goal of such a center is to optimize the treatment of patients. The center can help in drawing and interpreting the human chorionic gonadotrophin regression curve and give the multidisciplinary current recommendations to the physician in charge of the patient. The aim is to diagnose and treat as soon as possible the malignant forms of the disease as the interval between the previous pregnancy and the initiation of treatment is a major prognostic factor.

[Rubella in pregnancy. Management and prevention]

DECLINING INCIDENCE: Between 1982 and 1994, the incidence of rubella infections during pregnancy in France declined form 45 to 9 cases per 100,000 births. The incidence of congenital rubella declined from 5 to 0.85 per 100,000 births. These results are the fruit of systematic vaccination of 1-year-old children in France. Eradication of congenital rubella has been achieved in Sweden and requires further efforts to be obtained in our country. SEROLOGY: Physicians must systematically check rubella serologies in all women desiring pregnancy and/or of reproductive age even if they have been vaccinated. Rubella serology must be checked in all pregnant women even if they were seropositive during a prior pregnancy. IN CASE OF EXPOSURE OR ERUPTION DURING PREGNANCY: Serology must be obtained as early as possible in case of suspected rubella infection during pregnancy with a second serology 3 weeks later. The IgM titre should be obtained in case of suspected exposure with significant rise in IgG in successive serologies, if specific IgG titre is elevated after an eruption, if the first serum sample was taken late after suspected exposure, and finally if a systematic serology early in pregnancy is positive after a previously negative serology. ANTENATAL DIAGNOSIS: PCR on amniotic fluid or fetal blood is indicated if a seroversion occurs before 18 weeks gestation. Therapeutic termination of pregnancy should be proposed if fetal infection is certain. After 18 weeks, there is nearly no risk for the fetus: an antenatal diagnostic sample is not required and ultrasound surveillance is sufficient.

First case of pregnancy after radical trachelectomy and pelvic irradiation

BACKGROUND

Invasive carcinoma of the cervix above stage IA1 is usually treated by radical hysterectomy and/or radiotherapy, leading to definitive sterility.

CASE REPORT

We report the case of a young patient with stage IB1 carcinoma of the cervix treated in June 1995 by radical trachelectomy (according to the technique described by Dargent) and adjuvant brachy + teletherapy. A hormonal replacement of "menopause" was prescribed. One year later, she became pregnant and at 27 weeks gestation gave birth to a healthy child by cesarean section.

CONCLUSION

Radical trachelectomy is one of the most recent therapeutic steps forward in the treatment of early stage invasive cervical carcinoma, which can surely be treated in some cases preserving child-bearing potential.

Lichenoid cutaneous drug reaction at injection sites of granulocyte colony-stimulating factor (Filgrastim)

Colony-stimulating factors are widely used for bone marrow recovery after chemotherapy. Various cutaneous side-effects have been described in most cases involving neutrophils. We report the first case of lichenoid reaction at injection sites of granulocyte colony-stimulating factor (G-CSF) in a 40-year-old patient treated for breast cancer. The eruption cleared after drug withdrawal, no recurrence was observed after drug replacement by granulocyte-macrophage colony-stimulating factor. Mainly lymphocyte-mediated lichenoid eruption to G-CSF was shown. Cutaneous side-effects to G-CSF do not share unequivocal pathogeny based on stimulation of neutrophils.

[Hysterectomy for a benign lesion: can the vaginal route be used in all cases?]

OBJECTIVE

To determine which factors indicate the vaginal route cannot be used for hysterectomy and study the morbidity of this technique in comparison with the abdominal route.

METHODS

A retrospective study was conducted in 682 patients who underwent hysterectomy for benign lesions between 1992 and 1996. Genital prolapses and/or urinary incontinence accounted for 31% of the indications. Mean patient age was 50 years. There were 75 nulliparous patients and 27% of all patients had a pelvic history (including cesarean section) which might compromise vaginal hysterectomy.

RESULTS

Hysterectomy was performed via the abdominal route in 39.7% of the cases and via the vaginal route in 60.3% including 5.7% with laparoscopic assistance. Factors which dictated the abdominal route were: large size of the uterus (47%), pelvic background (30%), tubo-ovarian pathology (6%), multiple elements (6%), unknown (11%). Operation time depended on the surgical route, parity, pelvic background and associated techniques (prolapse, oophorosalpingectomy, uterine segmentation). Morbidity was very low and the same for both routes: 1.8% operative accidents (mainly bladder wounds), 1% reoperation, only one case of thromboembolism and less than 0.5% postoperative fever.

DISCUSSION

There is no absolute contraindication to vaginal hysterectomy. It would appear unreasonable to an unexperienced surgeon to use the vaginal route for a fixed uterus with an estimated weight over 400 g in nulliparous patients with a pelvic background. In a department with vaginal training, 84% of all hysterectomies could be performed by vaginal route, because half of the indications for the abdominal route are excessive or a matter for laparoscopic assistance.