Daniel Raudrant

Bowel Endometriosis: Preoperative Diagnostic Accuracy of 3.0-T MR Enterography—Initial Results

PURPOSE To prospectively determine the accuracy of 3.0-T magnetic resonance (MR) enterography in the preoperative assessment of deep infiltrating endometriosis (DIE) lesions located in the bowel above the rectosigmoid junction. MATERIALS AND METHODS Institutional review board approval for this study was obtained, and each patient gave written informed consent. Over 18 months, patients with known pelvic DIE who were scheduled for surgery were recruited. Consecutive patients suspected of having bowel endometriosis above the rectosigmoid junction underwent 3.0-T MR enterography. Two blinded readers independently performed a systematic analysis of nine bowel segments above the rectosigmoid junction. MR images were compared with surgical and pathologic findings. Efficacy parameters were calculated with 95% confidence intervals (CIs). Interobserver agreement was assessed with κ statistics. RESULTS Among the 43 patients enrolled in this study, 33 underwent surgery and were included in the final analyses. Sixteen (48%) patients had bowel DIE lesions located above the rectosigmoid junction at surgery and histopathologic examination. Twenty-six lesions were analyzed, including four ileal, two ileocecal, three cecal, three appendicular, and 14 sigmoid colon lesions. For the diagnosis of these lesions, MR imaging showed sensitivities of 92% (95% confidence interval [CI]: 81.7, 100) for reader 1 and 96% (95% CI: 87.1, 100) for reader 2 and specificities of 100% (95% CI: 98.8, 100) for both readers. The κ value was 0.97. CONCLUSION These results show 3.0-T MR enterography is accurate in the preoperative diagnosis and mapping of bowel DIE lesions located above the rectosigmoid junction. Online supplemental material is available for this article.

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.

Reappraisal of in utero Stem Cell Transplantation Based on Long-Term Results

The therapeutic field of in utero transplantation of stem cells, into human fetuses, has developed since 1988 with the hope of improved probability of engraftment and tolerance, due to immune immaturity of the host. Fifteen years later, it is possible to evaluate the results that we and others have obtained in the treatment of several fetal diseases. Seven fetal patients have been treated in Lyon: In 2 cases, pregnancy termination was induced by the in utero injection; in the 5 other cases, engraftment was obtained and repeatedly documented with presence of donor HLA antigens and/or Y chromosome in recipients. In the 2 patients with combined immunodeficiency disease, a sustained reconstitution of immunity was obtained as a result of the transplant but other complications occurred thereafter. In patients with thalassemia major, Niemann-Pick disease or hemophilia, a very partial and very transitory benefit was only obtained. Approximately 33 other patients with immunodeficiencies, hemoglobinopathies or inborn errors of metabolism have been treated worldwide, over the last 13 years, with a comparable method, using parental or fetal stem cells transplanted in utero. Successful treatment has usually been recorded in immunodeficiencies, and insufficient results have been obtained in the other cases. This form of treatment can therefore be recommended after prenatal diagnosis of combined immunodeficiency but additional research is required to improve the degree of engraftment, the lack of resistance of the host and the ‘space’ available for hematopoiesis in the other conditions.

Methotrexate for 2000 FIGO low-risk gestational trophoblastic neoplasia patients: efficacy and toxicity

OBJECTIVE We sought to review efficacy and toxicity of an 8-day methotrexate (MTX) regimen in the treatment of patients with low-risk gestational trophoblastic neoplasia (GTN) from the French Trophoblastic Disease Reference Center. STUDY DESIGN Between 1999 and 2006, 142 low-risk GTNs were diagnosed according to International Federation of Gynecology and Obstetrics (FIGO) criteria for GTN and to the FIGO scoring system. We report their characteristics, remission/resistance/recurrence rates, and treatment toxicity. RESULTS The 8-day MTX regimen achieved a 77.5% remission rate. All patients but 1 (99.9%) achieved remission and remained disease free until the time of analysis. Severe (grade 3 or 4) blood/bone marrow toxicity and metabolic/laboratory toxicity was noted in 4.2% of cases, of which 2 (1.4%) were grade 4. CONCLUSION For patients with GTN diagnosed according to FIGO criteria and considered low risk according to the FIGO scoring system, an 8-day MTX regimen is an adequate treatment associating a high rate of remission to a low rate of toxicity.

Contribution of referent pathologists to the quality of trophoblastic diseases diagnosis

OBJECTIVE To evaluate the contribution of referent pathologists (RPs) to the quality of diagnosis of trophoblastic diseases and to study the level of diagnostic agreement between the initial pathologists and the RPs. METHODS This observational retrospective study was carried between 1 November 1999 and 11 January 2011 using the database of the French Trophoblastic Disease Reference Centre in Lyon. All files for hydatiform moles (HMs), trophoblastic tumours and non-molar pregnancies for which there was an initial suspicion of trophoblastic disease were included, whenever there was rereading of the slides by an RP. A total of 1851 HMs and 150 gestational trophoblastic tumours were analysed. RESULTS When the initial pathologist diagnosed a complete mole, the RP confirmed the diagnosis in 96% of cases. When the initial pathologist diagnosed a partial mole, the RP confirmed the diagnosis in only 64% of cases. For trophoblastic tumours, when the initial pathologist diagnosed a choriocarcinoma, the RP confirmed the diagnosis in 86% of cases. When the initial anatomopathology suggested an invasive mole, the diagnosis was confirmed in 96% of cases. Finally, when the initial diagnosis was a placental site trophoblastic tumour or an epithelioid trophoblastic tumour, the RP confirmed the diagnosis in 60 and 100% of cases, respectively. CONCLUSION A systematic policy of rereading of slides for all suspicious moles improves the quality of management of trophoblastic diseases at a national level.

Placental site and epithelioid trophoblastic tumours: Diagnostic pitfalls

OBJECTIVE To describe the clinical and histological pitfalls in the diagnosis of placental site trophoblastic tumours (PSTT) and epithelioid trophoblastic tumours (ETT), two rare types of gestational trophoblastic neoplasia (GTN). METHODS This retrospective, observational, study was carried out in the French Trophoblastic Disease Reference Centre, Lyon, between 2000 and 2011. Due to the many similarities in the diagnosis, treatment and prognosis of PSTT and ETT, these two types of tumour were investigated together. Twenty-two patients with PSTT or ETT were analysed. RESULTS The clinical presentation of these two types of tumour was irregular vaginal bleeding (55%) or amenorrhoea (27%), with a median plasma hCG level of 205IU/L. Seven of the 22 patients (32%) were initially misdiagnosed as an ectopic pregnancy. Median age at presentation was 35-years, with a median interval of 12months between the antecedent pregnancy and diagnosis of PSTT or ETT. The initial histological diagnosis was incorrect in 7/18 (39%) patients; there was a major disagreement with the referral pathologist in five of these seven patients (28%). CONCLUSIONS PSTT and ETT are the most difficult types of GTN to diagnose clinically and histologically. An incorrect diagnosis can lead to significant therapeutic deviations from the recommended first-line treatment, namely hysterectomy. Clinical and histological expertise is essential to avoid the pitfalls in the diagnosis of PSTT and ETT.

Laparoscopic uterovaginal anastomosis in Mayer-Rokitansky-Küster-Hauser syndrome with functioning horn

OBJECTIVE To reestablish uterovaginal continuity using a total laparoscopic procedure in Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome with a functioning right horn. DESIGN Case report. SETTING University hospital of Hotel Dieu de Lyon. PATIENT(S) A 13-year-old woman with cyclic abdominal pain. We diagnosed MRKH syndrome with cyclic pain due to a hematometra in a functioning right horn associated to a right hematosalpinx and a nonfunctioning left horn. INTERVENTION(S) Reestablishing uterovaginal continuity with excision of the left rudimentary horn via a total laparoscopic procedure. MAIN OUTCOME MEASURE(S) Restoring regular menstruation. RESULT(S) After total laparoscopic uterovaginal anastomosis and excision of the left nonfunctioning horn, the patients menstruation resumed 3 months later, and regular, unimpeded menstrual flow was still present at the 2-year-follow-up evaluation. CONCLUSION(S) Total laparoscopic reestablishment of uterovaginal continuity in MRKH syndrome with a functioning horn is a valuable alternative to the currently recommended treatment (laparotomy and radical excision of the rudimentary uterus).

Axillary lymph node dissection in the case of sentinel lymph node micrometastatic invasion: evaluation of three predictive models

OBJECTIVE To evaluate three predictive risk models of non-sentinel lymph node (NSLN) involvement in the case of micrometastatic sentinel node (SLN) involvement for breast cancer. STUDY DESIGN This retrospective study included 72 successive patients with micrometastatic SLN involvement who had surgery between March 1996 and October 2007. All patients had undergone immediate or delayed axillary lymph node dissection (ALND). The Memorial Sloan-Kettering Cancer Center (MSKCC) nomogram, the Stanford nomogram and the Tenon score were applied to the population to calculate the probability of NSLN involvement. RESULTS For the MSKCC nomogram with a threshold value of 10%, sensitivity was 50%, specificity was 70% and the negative predictive value (NPV) was 89%. The area under the receiver operating characteristic curve (AUC) was 0.6 (significant). Use of this nomogram would have avoided ALND in 49 out of 72 (68%) patients, but five out of 10 (50%) patients with NSLN involvement would not have been detected. With a threshold value of 7%, the AUC was 0.69, sensitivity was 90% and NPV was 97%. ALND would have been avoided in 31 out of 72 (43%) patients, with a 3% chance of leaving metastases when abstaining from ALND. For the Tenon score with a threshold value of 3.5, sensitivity was 50%, specificity was 72% and the AUC was 0.62. This was not clinically applicable because eight out of 10 (80%) patients with NSLN involvement would not have been detected. For the Stanford nomogram, the results could not be interpreted because the AUC was not significant. CONCLUSION None of the tested models are sufficiently reliable for use in daily practice. The MSKCC nomogram showed the most encouraging results, especially for a threshold value of 7%, but this has not been validated in the literature. Complete axillary dissection should be performed in the case of micrometastatic SLN involvement until more data become available.

Prise en charge des maladies trophoblastiques gestationnelles

Molar pregnancies can be subdivided into complete (CM) and partial moles (PM) based on genetic and histopathological features. Complete moles are diploid and androgenic in origin, with no evidence of fetal tissue. Complete moles usually (75–80%) arise as a consequence of duplication of a single sperm following fertilisation of an ‘empty’ ovum. Some complete moles (20–25%) can arise after dispermic fertilisation of an ‘empty’ ovum. Partial moles are usually (90%) triploid in origin, with two sets of paternal haploid genes and one set of maternal haploid genes. Partial moles occur, in almost all cases, following dispermic fertilisation of an ovum. Ten percent of partial moles represent tetraploid or mosaic conceptions. In a partial mole, there is usually evidence of a fetus or fetal red blood cells.

Myomectomie hystéroscopique utilisant l’énergie bipolaire : vers un « 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.