Fabien Vidal

Evaluation of the sentinel lymph node algorithm with blue dye labeling for early-stage endometrial cancer in a multicentric setting.

Objectives Sentinel lymph node (SLN) removal may be a midterm between no and full pelvic dissection in early endometrial cancer. Whereas the use of blue dye alone in SLN detection has a poor accuracy, its integration in an SLN algorithm may yield better results and overcome hurdles such as the requirement of nuclear medicine facility. Methods Sixty-six patients with clinical stage I endometrial cancer were prospectively enrolled in a multicentre study between May 2003 and June 2009. Patent blue was injected intraoperatively into the cervix. We retrospectively assessed the accuracy of a previously described SLN algorithm consisting of the following sequence: (1) pelvic node area is inspected for removal of all mapped SLN and (2) excision of every suspicious non-SLN, (3) in the absence of mapping in a hemipelvis, a standard ipsilateral lymphadenectomy is then performed. Results Sentinel nodes were identified in 41 patients (62.1%), mostly in interiliac and obturator areas. None was detected in the para-aortic area. Detection was bilateral in 23 cases (56.1%). Seven patients (10.6%) had positive nodes. The false-negative rate was 40% using SLN detection alone. When the algorithm was applied, the false-negative rate was 14.3%. The use of a SLN algorithm would have avoided 53% of lymphadenectomies Conclusion Our multicentric evaluation validates the use of a SLN algorithm based on blue-only sentinel node mapping in early-stage endometrial cancer. The application of such SLN algorithm should be evaluated in a prospective context and might lead to decrease unnecessary lymphadenectomies.

Cervical cancer with paraaortic involvement: do patients truly benefit from tailored chemoradiation therapy? A retrospective study on 8 French centers

We retrospectively studied the therapeutic significance of extended-field radiotherapy combined with concurrent platinum-based chemotherapy for the management of cervical carcinoma with paraaortic spread. Treatment response and survival outcomes were evaluated. One hundred and fifteen women were retrospectively studied. Radiological staging was conducted in 101 (87.8%) patients and paraaortic lymphadenectomy in 78 (67.8%). Patterns of treatment comprised chemoradiation therapy (100%), intracavitary brachytherapy (81.7%), completion surgery (60%) and neoadjuvant chemotherapy (4.3%). Four-year overall and disease-free survivals were 32.7% and 28.8%, respectively. Progression and relapse mostly involved the locoregional area and distant organs, rather than the paraaortic area. Advanced FIGO stage at baseline was the most significant prognostic factor (HR=3.02, p=0.01). Despite systematic extended-field chemoradiation therapy, paraaortic involvement in cervical cancer is associated with poor survival outcomes. The patterns of progression and recurrence suggest the existence of occult metastatic disease at presentation. Additional systemic treatment might thus be beneficial.

Management of persistent occiput posterior position: a substantial role of instrumental rotation in the setting of failed manual rotation

Abstract Introduction: To compare the maternal and neonatal outcomes associated with Instrumental Rotation (IR) to operative vaginal delivery in occiput posterior (OP) position with Thierry’s spatulas (TS), in the setting of failed manual rotation (MR). Study design: We led a prospective observational cohort study in a tertiary referral hospital in Toulouse, France. All women presenting in labor with persistent OP position at full cervical dilatation and who delivered vaginally after failed MR and with IR or OP assisted delivery were included from January 2014 to December 2015. The main outcomes measured were maternal morbidity parameters including episiotomy rate, incidence and severity of perineal lacerations, perineal hematomas and postpartum hemorrhage. Severe perineal tears corresponded to third and fourth degree lacerations. Fetal morbidity outcomes comprised neonatal Apgar scores, acidemia, fetal injuries, birth trauma and neonatal intensive care unit admissions. Results: Among 9762 women, 910 (9.3%) presented with persistent OP position at full cervical dilatation and 222 deliveries were enrolled. Of 111 attempted IR, 97 were successful (87.4%). The incidence of anal sphincter injuries was significantly reduced after IR attempt (1.8% vs. 12.6%; p < 0.002). Both groups were similar regarding most fetal outcomes and no birth trauma occurred in our study population. In a multivariable logistic regression analysis, OP operative delivery was a significant risk factor of severe perineal lacerations (OR = 9.5; 95% CI: 2.05–44.05). Conclusion: Our results support the use of IR in order to reduce perineal morbidity associated with OP assisted delivery, in the setting of a failed manual rotation.

Vulvar necrosis after surgical treatment of femoral neck fracture: a case report and investigation of the mechanism of injury

We report the case of a young patient, presenting with total bilateral vulvar necrosis after reduction of a femoral neck fracture. This report describes the management of this complication, its mechanism of injury and the associated means of prevention. We present an investigation of the vulvar vasculature in order to understand the mechanism of injury. The study of the vulvar vasculature rejects the anatomical hypothesis of selective damage to the internal and external arteries. Instead, it suggests intraoperative impingement of the terminal blood vessels caused by compression against the perineal post prompting discussion on the use of moulded countertraction posts during orthopaedic surgery.

Motion estimation in ultrasound imaging applied to the diagnostic of pelvic floor disorders

The main purpose of this paper is to show the potential of tissue motion estimation in ultrasound imaging for the diagnostic of pelvic floor disorders. We propose to evaluate the tissue motion using a method based on a local deformable model and on image features (local phase and orientation) extracted from the monogenic signal. The proposed method is well adapted to the pelvic organ deformations and estimates motion with subpixel precision without the need for interpolation. The estimated motion is used to visualize the bladder local deformation and to extract quantitative figures such as the deformation parameters and the bladder angle variation. These results could potentially be interesting to characterize the degree of the pelvic organ prolapse.

Prospective study feasibility: Screening of antenatal total abnormal pulmonary venous return

Total abnormal pulmonary venous return is a heart defect often missed prenatally, yet at birth, it is a surgical emergency. Antenatal detection could be improved by sonographic visualization of the anastomosis of 2 pulmonary veins in a sinus into the left atrium. The objective of this study is to evaluate the feasibility of this screening method.

Comment on: Higher Rates of Operative Delivery and Maternal and Neonatal Complications in Persistent Occiput Posterior Position with a Large Head Circumference: A Retrospective Cohort Study

Dear Editor We read with interest the study by Yagel et al. [1], who investigated whether a large head circumference (HC) in the setting of persistent occiput posterior (OP) position was associated with maternal and neonatal complications using a retrospective cohort study. The main finding highlights that a large HC was a risk factor of operative deliveries and NICU admissions. This study emphasizes the major morbidity associated with OP deliveries particularly among primiparae, which is a real obstetrical challenge. We would like to point out that these results confirm the importance of recognizing the variety of fetal presentation and suggest the benefit of manual rotation (MR). MR from the OP to the occiput anterior (OA) position is a safe and effective procedure, which allows to significantly reduce the rate of caesarean sections and operative deliveries without increasing neonatal morbidity [2]. According to the results by Yagel et al. [1], MR seems all the more relevant in case of large HC. In this subgroup, fetal head rotation from OP to OA could thus decrease OP-associated morbidity, as they found an increased perinatal morbidity in the OP group combined with HC compared to the OA position: operative deliveries, caesarean section, prolonged second stage of labor, and umbilical arterial pH ≤7.1 [1]. Furthermore, a large HC does not seem to be a risk factor of MR failure [2]. Consistently, the ACOG/SMFM Obstetrics Care Consensus [3] has recommended an MR attempt before OP operative delivery. Ongoing prospective trials are currently addressing the efficiency of elective MR in the management of OP position in the second stage of labor in the prevention of operative delivery [4].

Operative vaginal delivery in case of persistent occiput posterior position after manual rotation failure: a 6-month follow-up on pelvic floor function

AbstractPurposeTo compare the short- and long-term perineal consequences (at 6 months postpartum) and short-term neonatal consequences of instrumental rotation (IR) to those induced by assisted delivery (AD) in the occiput posterior (OP) position, in case of manual rotation failure.MethodsA prospective observational cohort study; tertiary referral hospital including all women presenting with persistent OP position who delivered vaginally after manual rotation failure with attempted IR or AD in OP position from September 2015 to October 2016. Maternal and neonatal outcomes of all attempted IR deliveries were compared with OP operative vaginal deliveries. Main outcomes measured were pelvic floor function at 6 months postpartum including Wexner score for anal incontinence and ICIQ-FLUTS for urinary symptoms. Perineal morbidity comprised severe perineal tears, corresponding to third and fourth degree lacerations. Fetal morbidity parameters comprised low neonatal Apgar scores, acidaemia, major and minor fetal injuries and neonatal intensive care unit admissions. ResultsAmong 5265 women, 495 presented with persistent OP positions (9.4%) and 111 delivered after manual rotation failure followed by AD delivery: 58 in the IR group and 53 in the AD in OP group. The incidence of anal sphincter injuries was significantly reduced after IR attempt (1.7% vs. 24.5%; p < 0.001) without increasing neonatal morbidity. At 6 months postpartum, AD in OP position was associated with higher rate of anal incontinence (30% vs. 5.5%, p = 0.001) and with more urinary symptoms, dyspareunia and perineal pain.ConclusionsOP operative deliveries are associated with significant perineal morbidity and pelvic floor dysfunction at 6 months postpartum.

Conservative versus active management in HELLP syndrome: results from a cohort study

Abstract Objective: HELLP syndrome exposes to severe maternal and fetal complications. Prompt delivery is thus recommended after 34 weeks of gestation, or earlier in case of nonreassuring maternofetal conditions. However, no consensus has been raised in the treatment of HELLP syndrome occurring before 34 weeks of gestation, when both maternal and fetal conditions are stable: it remains still unclear whether an active attitude should be prioritized over expectant management. Herein, we aimed to compare mother and child outcomes according to the type of obstetrical management, either active or conservative. Study design: Retrospective and multicenter study involving two tertiary care units. In Center A, obstetrical attitude consisted in expectant management: all women received full antenatal betamethasone therapy and pregnancy was prolonged until maternal or fetal follow up indicated delivery. In Center B, management was active: all deliveries were initiated within 48 hours following diagnosis. Results: From 2003 to 2011, 118 patients were included (87 in Center A, 31 in Center B). Both groups of patients were similar regarding maternal and fetal features at baseline. Active management led to increased risks of post-partum hemorrhage (relative risks (RR) = 5.38, 95%CI: 1.2–24.06) and neonatal morbidity including respiratory distress syndrome (RR = 3.1, 95%CI: 1.4–7.1), sepsis (RR = 2.5, 95%CI: 1.1–6.0), necrotizing enterocolitis (RR = 4.8, 95%CI: 1.1–21.2), intracerebral hemorrhage (RR = 5.4, 95%CI: 2.1–13.6), and blood transfusion (RR = 6.1, 95%CI: 1.7–21.7). Conclusions: Conservative management may be beneficial for both mother and newborn in patients with stable HELLP syndrome. Identification of maternal and fetal specific prognostic factors would allow a better stratification of women with HELLP syndrome according to illness progressive potential, resulting in a more personalized management.

Bilateral femur metastases in low-grade endometrial carcinoma.

Lower‐limb bone metastases are uncommon in low‐grade endometrial carcinoma, and are mostly located on the axial skeleton. Here, we present a rare case of bilateral femur metastases in low‐grade endometrial carcinoma and performed a review of the current literature.