E. Barranger

Individual xenograft as a personalized therapeutic resort for women with metastatic triple-negative breast carcinoma

A localized left breast ductal invasive triple-negative breast carcinoma (TNBC) was diagnosed in a 44-year-old woman. After surgery, she was treated with chemotherapy and radiation therapy in accordance with national guidelines. At the end of treatment, she had local and metastatic relapse with multiple sub-diaphragmatic lymph nodes.

Prise en charge des lymphocèles après curage axillaire dans le cancer du sein

Since the advent of sentinel node biopsy, which made it possible to reduce the morbidity of axillary surgery, axillary lymph node dissection has been constituting the treatment of reference in certain cases of breast cancer. One of the most frequent complications in the immediate postoperative period is the lymphocele or seroma, the frequency of which is independent of the axillary technique of surgery. Following an analysis of the literature, some risk factors were isolated such as a high body mass index, the high volume of the first three days drainage and arterial hypertension. Some techniques seem to show a benefit in the reduction of the lymphocele: sentinel node biopsy, padding of the axilla and the axillary drainage. The majority of other techniques such as the use of fibrin sealant, hemolymphostatic sponges, various techniques of axillary dissection, external axillary compression, differed mobilization from the upper limb, axillary dissection by lipo-aspiration and endoscopic axillary dissection, have too contradictory results at the present time to be recommended in clinical practice. No consensus is clearly established to decrease the incidence and the volume of the seroma after axillary dissection in breast cancer. Today, two techniques can be nevertheless distinguished: sentinel node biopsy and padding of the axilla.

Intrathecal Trastuzumab Halts Progression of CNS Metastases in Breast Cancer

Introduction Since its approval, trastuzumab has greatly improved the prognosis of patients with human epidermal growth factor receptor 2 (HER2) –overexpressing metastatic breast cancer. However, these patients are at higher risk of developing CNS metastases. The benefit of intrathecal trastuzumab for the treatment of brain or epidural metastases has not yet been addressed, to our knowledge. We report here the efficacy of intraventricular trastuzumab administration, guided by repeated pharmacokinetic analyses and a trastuzumab trough concentration (Cmin) target of more than 10 mg/L, in stabilizing brain and epidural metastases of HER2-overexpressing breast cancer.

Placenta accreta : dépistage, prise en charge et complications

Abnormal placental invasion can result in major obstetric haemorrhage during delivery. The most important risk factors are the following: previous caesarean delivery, placenta praevia maternal age over 35, smoking, previous myomectomy, dilatation and curettage. When placenta accreta is suspected on ultrasound, an RMI can complete the diagnostic. Therefore, patients must be managed, as far as possible, in a reference centre, by a trained medical team. Birth must be planned in order to decrease complications rate. Treatment can consist in radical management (caesarean-hysterectomy) or conservative management (preservation of both uterus and placenta). Conservative management allows patients to keep fertility but can also decrease blood loss during delivery. Side effects of this therapy are secondary haemorrhage, sepsis, long-term follow-up and vaginal loss. There are few studies describing fertility after conservative management, but it seems to be a secure treatment for future pregnancies. Embolization can be a very useful, already demonstrated, help when massive haemorrhage occurs. Management of placenta accreta is multidisciplinary and patients must be informed of all options. Treatment is decided regarding history of the patients, operative findings and peri-partum blood loss.

Tachosil® to reduce the morbidity of axillary lymph node dissection in breast cancer

S1 Assessing prognosis for early breast cancer: clinical versus genetic profiles GN Hortobagyi Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA Breast Cancer Research 2007, 9(Suppl 1):S1 (doi: 10.1186/bcr1684) Since the introduction of systemic adjuvant chemotherapy (ACT) and endocrine therapy in the early 1970s, the determination of risk of recurrence and death from breast cancer became a critical piece of information in the selection of the optimal postoperative treatment strategy. Classical histopathological prognostic factors included tumor size, regional lymph node metastases and number of axillary nodes involved, tumor grade, presence of lymphovascular invasion, and, more recently, estrogen receptor (ER) and progesterone receptor status, measurement of proliferative activity (S-phase fraction, mitotic index, Ki-67), and HER2 overexpression/amplification. As isolated factors, they have limited predictive ability in the case of individual patients. For that reason, prognostic indices were developed. The most successful is Adjuvant!Online, an online nomogram developed by Peter Ravdin. This nomogram incorporates tumor size, axillary nodal status, tumor grade, ER status, age and comorbidity. The nomogram will provide an assessment of recurrence and mortality rates at 10 years, including deaths due to comorbid conditions. In addition, the nomogram also calculates relative and absolute benefit from various adjuvant interventions: tamoxifen, aromatase inhibitors, and first-generation, secondgeneration and third-generation ACT regimens. The prognostic and predictive value of this nomogram has been externally validated, with a margin of error ≤1%. Over the past decade, high-throughput technologies have been developed based on gene expression profiling. These include between two and a couple of hundred genes, and have the ability to separate patients with excellent outcomes from those with higher risk. One of these prognostic profiles has been externally validated and is currently undergoing testing for clinical utility in a large, multicenter, prospective randomized trial (MINDACT). Another approach was based on prospectively identifying a set of genes from the literature and from the results of gene expression profiling. Mathematical modeling then led to the selection of 16 genes related to cell proliferation, ER-driven genes, HER2 and proteases, as well as five ‘housekeeping’ genes (OncotypeDx). This assay is based on RT-PCR, is reproducible and applicable to archival, paraffin-embedded material, and has been shown to predict prognosis in patients with lymph-nodenegative, ER-positive primary breast cancer. Further testing indicated that the assay might also predict sensitivity to tamoxifen, or firstgeneration adjuvant chemotherapy. This assay is also under evaluation for clinical utility in a large, multicenter, prospective randomized trial (TailoRx). Whether these multigene predictors of prognosis will have greater utility than Adjuvant!Online remains to be determined. In the meantime, exploratory analyses are ongoing to identify reliable predictors of response to individual drugs and modern combination drug regimens. These are expected to lead to individualized selection of treatment, or personalized medicine.

Emergency hysterectomy for life-threatening postpartum haemorrhage: Risk factors and psychological impact.

BACKGROUND Emergency postpartum hysterectomy (EPH) is usually considered the final resort for the management of postpartum hemorrhage (PPH). The aim of this observational study was to identify the risk factors for EPH, to evaluate the ability of EPH to stop bleeding and, finally, to estimate its psychological impact. METHODS This was a retrospective analysis of postpartum hysterectomy in all patients with PPH admitted between 2004 and 2011 to Lariboisière Hospital. We compared women for whom EPH was successful and those who required an advanced interventional procedure (AIP) to stop the bleeding despite hysterectomy. We also evaluated the severe PPH (SPPH) score in this particular setting. The psychological impact of emergency hysterectomy was also assessed. RESULTS A total of 44 hysterectomies were performed among 869 cases of PPH. Twenty were successful, while an additional AIP was required in 22 others (50%). Prothrombin time<50% and a shorter interval between the onset of PPH and hysterectomy were independently associated with the need for an additional AIP. The area under the ROC curve of the SPPH score to predict the need for another AIP was 0.738 (95% confidence interval 0.548-0.748). Furthermore, 64% of the hysterectomized patients suffered from post-traumatic stress disorder. CONCLUSION Failure of postpartum hysterectomy to control bleeding was frequent, and it was associated with persistence of coagulopathy. Hysterectomy in this context had important psychological impacts.

Stadification ganglionnaire des cancers du col utérin avancé

Lymph node staging in patients with locally advanced cervical cancer is the most important prognostic factor and also leads to adjuvant treatment choice. Because of the lymphadenectomy associated morbidity and delay in the beginning of adjuvant therapy, noninvasive approaches were developed during the last decennia. Recently, positron emission tomography employing a glucose analogue (FDG-PET) has been shown to be more sensitive and more specific than magnetic resonance imaging or than computed tomography usually used in diagnosis of pelvic and para-aortic lymph node metastases. Even if recent studies have reported promising results, surgical pelvic and para-aortic staging remains actually the most accurate procedure for evaluating lymph node metastases. This procedure should be accomplished by transperitoneal or extraperitoneal laparoscopy, with the benefits of minimal morbidity, shorter length of hospital stay and no significant increase of complications comparing to laparotomy approach. Laparoscopy also allows an early start of adjuvant treatment, this delay constituting an important prognostic factor for patients with locally advanced cancer. However, the survival benefit of lymph node dissection is still controversial and should be proved in randomised studies.

Ventouse Kiwi® versus forceps et spatules: évaluation de la morbidité maternelle et fœtale. À propos de 169 cas

AIM To evaluate maternal and fetal complications resulting from the use of the Kiwi vacuum extractor and to compare them with those resulting from the use of forceps or spatula. PATIENTS AND METHODS Patients who had instrumental extraction between November 2006 and April 2007 were included in a unicentric retrospective study. Complications resulting from the use of Kiwi vacuum extractor and those of other instruments were compared. RESULTS One hundred and sixty-nine patients where included, 79 had extraction with Kiwi vacuum extractor. The two populations (women having extraction with Kiwi and woman having extraction with spatula or forceps) were similar in terms of maternal characteristics, progress of labour and delivery. The rate of episiotomies was significantly lower with KIWI (73.1% versus 94.4%; P=0.0001), as well as was postpartum haemorrhage rate (8.9 % versus 18.9%; P=0.04). No perineal tear of second or third degree occurred with Kiwi. Kiwi vacuum extractor was associated with a higher rate of shoulder dystocia (12.8% versus 6.7%, NS), but related fetal complication rates were similar in the two groups. The extraction failure rate was significantly higher with Kiwi (11.4% versus 4.4%; P=0.04), but cesarean section rate was similar for the two groups (1.3 % versus 4.4%). DISCUSSION AND CONCLUSION This study is the first comparing complications occurring after extraction with KIWI vacuum extractor to those occurring with other instruments. Although the results are limited by the retrospective nature of the study and the small size of the workforce, our study suggests that Kiwi vacuum extractor is associated with a lower rate of maternal complications and a rate of fetal complication similar to other kind of instruments. This instrument should be promoted and taught to younger patricians. Our study also revealed higher failure and shoulder dystocia rates. Larger studies are needed to better evaluate risks factor concerning these two complications in order to optimise the use of Kiwi vacuum extractor.

État des lieux des transferts pour hémorragie de la délivrance dans un centre de référence (hôpital Lariboisière) en 2008 et 2009

OBJECTIVES The postpartum haemorrhage (PPH) is the main cause of maternal mortality and is responsible in France every year of a quarter of the maternal deaths. We realized a study on the transfers for postpartum haemorrhage in 2008 and 2009 in a Reference center (Lariboisière Hospital). PATIENTS AND METHODS It is a descriptive retrospective study over a period of two years, including all the patients cared for a postpartum haemorrhage. RESULTS Two hundred and ninety-nine patients were cared for a PPH in 2008 and 2009 at the hospital Lariboisière. For transferred patients, the average age of the patients was of 30.9 years with varying extremes from 16 to 43 years old. It was the first pregnancy for 45.4% of the patients, having given birth to singletons (90.3%) by natural way in 63.8% of the cases. The care on arrival to Lariboisière based on surveillance in recovery room in 71.4% of the cases. The rate of embolisation was 22.4% and was stable over these two periods. DISCUSSION AND CONCLUSION A supervision in recovery room associated with measures of resuscitation and with use of prostaglandins is mostly sufficient for the most part of the care of the PPH. In case of persistent bleeding, the embolisation remains an excellent therapeutic option and a good alternative in the hysterectomy of haemostasis, which however has to keep its place in severe PPH.

Article originalÉtat des lieux des transferts pour hémorragie de la délivrance dans un centre de référence (hôpital Lariboisière) en 2008 et 2009Transfers for postpartum haemorrhage in a Reference center (Lariboisière hospital): Our experience during two years (2008 and 2009)

OBJECTIVES The postpartum haemorrhage (PPH) is the main cause of maternal mortality and is responsible in France every year of a quarter of the maternal deaths. We realized a study on the transfers for postpartum haemorrhage in 2008 and 2009 in a Reference center (Lariboisière Hospital). PATIENTS AND METHODS It is a descriptive retrospective study over a period of two years, including all the patients cared for a postpartum haemorrhage. RESULTS Two hundred and ninety-nine patients were cared for a PPH in 2008 and 2009 at the hospital Lariboisière. For transferred patients, the average age of the patients was of 30.9 years with varying extremes from 16 to 43 years old. It was the first pregnancy for 45.4% of the patients, having given birth to singletons (90.3%) by natural way in 63.8% of the cases. The care on arrival to Lariboisière based on surveillance in recovery room in 71.4% of the cases. The rate of embolisation was 22.4% and was stable over these two periods. DISCUSSION AND CONCLUSION A supervision in recovery room associated with measures of resuscitation and with use of prostaglandins is mostly sufficient for the most part of the care of the PPH. In case of persistent bleeding, the embolisation remains an excellent therapeutic option and a good alternative in the hysterectomy of haemostasis, which however has to keep its place in severe PPH.