Charles Coutant

Anaphylactic response to blue dye during sentinel lymph node biopsy

The sentinel lymph node (SLN) procedure is now used routinely for the staging of clinically node-negative patients with early breast cancer. Two identification techniques exist: colorimetric and isotopic. These can be used alone or in combination. The combined method is associated with an increased identification rate. However, allergic and adverse reactions to blue dyes have been reported. The objective of this review was to determine the incidence of such events and to discuss alternative approaches. The authors conducted a search of the MEDLINE and EMBASE databases for reports of anaphylactic responses to isosulfan blue dye and patent blue V dye. Allergic reaction to the dyes isosulfan blue and patent blue V is rare and the reported incidence varies between 0.07% and 2.7%. Methylene blue dye appears to be safer, with no cases of allergic events having been reported. However, allergy tests in some patients have proven that there is cross-reactivity between isosulfan blue dye and methylene blue dye. Even though the risk of an anaphylactic response is low, this raises questions about the usefulness of colorimetric detection of SLN and whether alternatives to the use of the isosulfan and patent blue V dyes, such as methylene blue, exist.

Multiple synchronous (multifocal and multicentric) breast cancer: Clinical implications

Multifocality in breast cancer is a frequent phenomenon, whose prevalence may vary between 13 and 75%. The differences in estimation of the prevalence of multifocality across studies may be explained by the differing definitions used for multifocality and multicentricity; this inconsistency makes it difficult to analyze the literature on the subject. The incidence of multifocality is probably often underestimated. Currently, the diagnosis relies on imaging. The performance of mammography is relatively low, but the addition of breast ultrasonography can improve diagnostic sensitivity. Recently, breast magnetic resonance imaging (MRI) has been shown to be more accurate for detecting multifocality compared to conventional imaging. However, this modality is associated with high rates of false-positives that could result in inappropriate disease management. Thus, the use of MRI is not recommended as a first-line technique for diagnosing multifocality. The diagnosis of multifocality is important for breast cancer management, particularly with regards to the choice of surgery. A finding of multifocality may spur a decision to perform a wider excision that will avoid positive margins. Regarding the results of conservative surgery in the presence of multifocality, studies are contradictory, and no international consensus exists. Multifocality may also modify the management of the axillary basin; studies have shown that multifocality is associated to an over-risk of 20% of lymph node invasion. The sentinel node biopsy has been considered as an alternative to complete axillary lymph node dissection by the American Society of Clinical Oncology. The prognostic value of multifocality is still not well known, although some studies have suggested that it is associated with a worst prognosis. Further studies are needed to better assess the impact of multifocality on breast cancer prognosis.

Sentinel lymph node biopsy in gynaecological cancers: The importance of micrometastases in cervical cancer

Lymph node metastases is a recognized prognostic factor in women with cervical cancer. However, there is a need for consensual histological definition of micrometastases in this indication which could give rise to a classification system similar to that used in breast cancer. We thus conducted a MEDLINE and EMBASE database analysis to evaluate the concept of micrometastases in cervical cancer. Retrospective studies place the incidence of micrometastasis between 1.5 and 15% depending on the technique used to evaluate lymph node status. Sentinel lymph node biopsy with serial sectioning and immunohistochemical analysis appears to be the most accurate micrometastases detection technique. The value of RT-PCR in micrometastases detection remains to be clarified by further studies. From a clinical view point, few data are available to support the prognostic relevance of micrometastases. However, case control and longitudinal studies have underlined the risk of recurrence in women with micrometastases, raising the issue of a revision of adjuvant therapy indications in this specific population.

Urinary dysfunction after colorectal resection for endometriosis: results of a prospective randomized trial comparing laparoscopy to open surgery

OBJECTIVEnTo evaluate urinary symptoms before and after colorectal resection for endometriosis using validated questionnaires.nnnSTUDY DESIGNnWe randomly assigned 52 patients with colorectal endometriosis to undergo laparoscopically assisted or open colorectal resection. The median follow-up was 19 months. Urinary symptoms were evaluated using the International Prostate Score Symptom and the Bristol Female Low Urinary Tract Symptoms questionnaires.nnnRESULTSnDysuria was observed in 29% of cases postoperatively. Using Bristol Female Low Urinary Tract Symptoms and International Prostate Score Symptom scores, an alteration was observed for voiding symptoms (P = .01 and P = .006, respectively). No difference was observed between the laparoscopy and the open surgery group. An alteration of the International Prostate Score Symptom voiding symptoms was observed in the group that did not undergo nerve sparing surgery (P = .048). An alteration of the International Prostate Score Symptom voiding symptoms was observed for patients who underwent vaginal resection (P = .01) and parametrial resection (P = .02).nnnCONCLUSIONnOur findings confirm that colorectal resection for endometriosis is a source of urinary dysfunction whatever the surgical route.

Determinant factors of fertility outcomes after laparoscopic colorectal resection for endometriosis.

OBJECTIVEnThe aims of this prospective study were to evaluate fertility, pregnancy outcomes and their determinant factors after laparoscopic segmental colorectal resection for endometriosis.nnnSTUDY DESIGNnWe studied 83 women who underwent colorectal resection for endometriosis. Thirty-nine women (47%) had an associated infertility and 51 (61.4%) wished to conceive after surgery. Surgical route was exclusive laparoscopy in 77 cases (92.7%) and laparoconversion in 6 (7.3%).nnnRESULTSnTwenty-nine pregnancies were obtained in 24 patients (43.6%) including 20 spontaneous (69%) and 9 by IVF (31%). The median time to conceive spontaneously was 6 months and 20 months by IVF. Among the 39 infertile women, 18 (46%) conceived during the study period. A relation was found between pregnancy rate and patient age (p=0.02). Reduction in pregnancy rate was correlated to the presence of adenomyosis (p=0.04) and high ASRM total score (p<0.001) as well as exclusive laparoscopy compared to conversion to laparotomy for colorectal resection (p=0.01).nnnCONCLUSIONnAdenomyosis and conversion to laparotomy as well as patient age, ASRM score appeared determinant factors of fertility outcome.

Limits of lymphoscintigraphy for sentinel node biopsy in women with endometrial cancer.

OBJECTIVEnLymph node status in endometrial cancer is a major prognostic factor. Sentinel lymph node (SLN) biopsy using radiocolloid and blue dye labeling has emerged as an alternative to systematic lymphadenectomy. This technique requires a preoperative lymphoscintigraphy. The aim of this study was to evaluate the limits of day-before preoperative lymphoscintigraphy to SLN biopsy.nnnMETHODSnBetween July 2002 and March 2007, 38 patients with endometrial cancer underwent laparoscopic SLN procedure using radiocolloid and blue dye. Those with early-stage I endometrial cancer (35 patients) underwent a SLN procedure followed by systematic pelvic lymphadenectomy and a hysterectomy with bilateral salpingo-oophorectomy while those with presumed stage IIB on MR imaging (3 patients) underwent a radical hysterectomy. Omentectomy and paraaortic lymphadenectomy were also performed for women with clear cell or serous papillary carcinoma (5 patients). The SLN identification rates and false-negative rates were studied.nnnRESULTSnThe detection rate of lymphoscintigraphy was 84.5% (32/38), with 1.9 nodes per patient. Eight of 17 patients (47%) with unilateral sentinel lymph node on lymphoscintigraphy had bilateral SLNs at surgery and three of 15 patients (20%) with bilateral SLN on lymphoscintigraphy had unilateral SLN at surgery. The correlation was poor (kappa=0.266). When categorized in <2 and > or =2 sentinel nodes, the correlation between lymphoscintigraphic and surgical SLN mapping was moderate (kappa=0.33).nnnCONCLUSIONnOur results demonstrated the low correlation between day-before lymphoscintigraphy and surgical SLN mapping raising issues of its usefulness and cost-effectiveness in routine practice.

Ultrastaging of lymph node in uterine cancers

BackgroundLymph node status is an important prognostic factor and a criterion for adjuvant therapy in uterine cancers. While detection of micrometastases by ultrastaging techniques is correlated to prognosis in several other cancers, this remains a matter of debate for uterine cancers. The objective of this review on sentinel nodes (SN) in uterine cancers was to determine the contribution of ultrastaging to detect micrometastases.MethodsReview of the English literature on SN procedure in cervical and endometrial cancers and histological techniques including hematoxylin and eosin (H&E) staining, serial sectioning, immunohistochemistry (IHC) and molecular techniques to detect micrometastases.ResultsIn both cervical and endometrial cancers, H&E and IHC appeared insufficient to detect micrometastases. In cervical cancer, using H&E, serial sectioning and IHC, the rate of macrometastases varied between 7.1% and 36.3% with a mean value of 25.8%. The percentage of women with micrometastases ranged from 0% and 47.4% with a mean value of 28.3%. In endometrial cancer, the rate of macrometastases varied from 0% to 22%. Using H&E, serial sectioning and IHC, the rate of micrometastases varied from 0% to 15% with a mean value of 5.8%. In both cervical and endometrial cancers, data on the contribution of molecular techniques to detect micrometastases are insufficient to clarify their role in SN ultrastaging.ConclusionIn uterine cancers, H&E, serial sectioning and IHC appears the best histological combined technique to detect micrometastases. Although accumulating data have proved the relation between the risk of recurrence and the presence of micrometastases, their clinical implications on indications for adjuvant therapy has to be clarified.

Results of first in vitro fertilization cycle in women with colorectal endometriosis compared with those with tubal or male factor infertility

This retrospective study of women undergoing IVF (29 with colorectal endometriosis, 157 with tubal factor infertility, and 340 with male factor infertility) found similar fertility outcomes between the groups.

Does the use of the 2009 FIGO classification of endometrial cancer impact on indications of the sentinel node biopsy

BackgroundLymphadenectomy is debated in early stages endometrial cancer. Moreover, a new FIGO classification of endometrial cancer, merging stages IA and IB has been recently published. Therefore, the aims of the present study was to evaluate the relevance of the sentinel node (SN) procedure in women with endometrial cancer and to discuss whether the use of the 2009 FIGO classification could modify the indications for SN procedure.MethodsEighty-five patients with endometrial cancer underwent the SN procedure followed by pelvic lymphadenectomy. SNs were detected with a dual or single labelling method in 74 and 11 cases, respectively. All SNs were analysed by both H&E staining and immunohistochemistry. Presumed stage before surgery was assessed for all patients based on MR imaging features using the 1988 FIGO classification and the 2009 FIGO classification.ResultsAn SN was detected in 88.2% of cases (75/85 women). Among the fourteen patients with lymph node metastases one-half were detected by serial sectioning and immunohistochemical analysis. There were no false negative case. Using the 1988 FIGO classification and the 2009 FIGO classification, the correlation between preoperative MRI staging and final histology was moderate with Kappa = 0.24 and Kappa = 0.45, respectively. None of the patients with grade 1 endometrioid carcinoma on biopsy and IA 2009 FIGO stage on MR imaging exhibited positive SN. In patients with grade 2-3 endometrioid carcinoma and stage IA on MR imaging, the rate of positive SN reached 16.6% with an incidence of micrometastases of 50%.ConclusionsThe present study suggests that sentinel node biopsy is an adequate technique to evaluate lymph node status. The use of the 2009 FIGO classification increases the accuracy of MR imaging to stage patients with early stages of endometrial cancer and contributes to clarify the indication of SN biopsy according to tumour grade and histological type.

Nomogram to predict pregnancy rate after ICSI–IVF cycle in patients with endometriosis

BACKGROUNDnAlthough several scoring systems have been published to evaluate the pregnancy rate after ICSI-IVF in infertile patients, none of them are applicable for patients with deep infiltrating endometriosis (DIE) nor can they evaluate the chances of pregnancy for individual patients. The aim of this study was to develop a nomogram based on an association of patients characteristics to predict the clinical pregnancy rate in patients with endometriosis.nnnMETHODSnThis prospective longitudinal study was conducted from January 2007 to June 2010. The nomogram was built from a training cohort of 94 consecutive patients (141 ICSI-IVF cycles) and tested on an independent validation cohort of 48 patients (83 ICSI-IVF cycles). DIE was confirmed in all participants.nnnRESULTSnThe pregnancy rate (per patient) in women with and without DIE was 58 and 83%, respectively (P = 0.03). Increased patient age (P = 0.04), serum anti-Mullerian hormone (AMH) level ≤ 1 ng/ml (P = 0.03) and increased number of ICSI-IVF cycles (P = 0.03) were associated with a decreased clinical pregnancy rate. The presence of DIE was the strongest determinant factor of the clinical pregnancy rate in our model [odds ratio = 0.26, 95% confidence interval (CI): 0.07-0.9 (P = 0.006)], which also included patient age, serum AMH level and number of attempts at ICSI-IVF. The nomogram showed an area under the curve (AUC) of 0.76 for the training cohort (95% CI: 0.7-0.8) and was well calibrated. The AUC for the validation cohort was 0.68 (95% CI: 0.6-0.75) and calibration was good.nnnCONCLUSIONSnOur nomogram provides realistic and precise information about ICSI-IVF success and can be used to guide couples and practitioners.