Jean-Jacques Baldauf

Corticosteroid therapy for conservative management in marginally-viable pregnancy complicated by HELLP syndrome

Sir, We observed in each case an improvement or a stabilizaWe just read with interest the recent paper from Tsattion in the biological parameters (platelet count, SGOT, saris V. et al. about conservative management in HELLP SGPT, LDH). Table 1 summarizes the evolution of two of syndrome [1]. We would share our experience about this these parameters. The mean interval between corticosteroid subject as we have collected prospectively six cases of therapy and delivery or fetal demise was 5.5 days ranging HELLP syndrome that we have treated conservatively. from 1 to 17 (1, 5, 2, 3, 17 and 5 days, respectively). In Recently, some investigative groups have carried out cases 2 and 3, postponement before intrauterine fetal death conservative management in severe pre-eclampsia with or was 5 and 2 days, respectively. All the neonates but the without HELLP [2]. These series used haemodynamic two stillborn were delivered by a cesarean section. In these monitoring in intensive care units. Few other reports have four cases, termination of pregnancy was decided because described the benefits of antepartum corticosteroids on of fetal distress. Neither deterioration of the biological laboratory parameters [3,4]. parameters nor aggravation of the maternal hypertension The aim of this prospective study was to determine if were the indication for the cesarean section. steroid therapy could improve biological parameters in marginally-viable pregnancy (,30 weeks) complicated by Table 1 Changes in laboratory parameters following administration of dexaHELLP syndrome in order to postpone delivery and obtain methasone fetal lung maturity. Criteria of exclusion were (1) severe uncontrolled pre-eclampsia, (2) fetal distress, or (3) gestaBefore Day 1 Day 2 Day 4 Day 13 treatment tional age equal or more than 30 weeks. The mean gestational age at inclusion was 27 weeks ranging from 25 Platelet count 9 (310 /L) to 29. Our criteria to define HELLP syndrome were the case 1 88 95 same as reported by Barton and Sibai [5]. After inclusion, case 2 51 95 140 244 10 mg of intramuscular dexamethasone were given every case 3 95 139 133 12 hours until delivery. case 4 78 74 118 The particularity of our series is that all cases were case 5 77 79 140 266 244 9 case 6 81 84 96 115 severe HELLP syndrome with platelet count ,100310 /L a SGOT (U/L) which was not the case for Tsatsaris and Magann’s reports case 1 77 53 [1,4]. Two women had stillbirth at 25 weeks gestation. In case 2 130 70 28 18 these two cases (cases 2 and 3), we only retained biocase 3 151

Does the Number of Neoadjuvant Chemotherapy Cycles before Interval Debulking Surgery Influence Survival in Advanced Ovarian Cancer

Objective: To evaluate the overall survival (OS) of patients with initially inoperable advanced ovarian cancer, tubal carcinoma, or primary peritoneal carcinoma of stages III or IV undergoing neoadjuvant chemotherapy (NAC) followed by cytoreductive surgery, according to the number of cycles performed. Methods: This retrospective study was conducted in three main oncology centres in the east of France, reviewing the charts of all patients who underwent NAC between January 1, 1998 and October 31, 2012. We performed an OS analysis using multivariate Cox regression models adjusted for potential confounders. We also analysed progression-free survival (PFS) as well as chemotherapy- and surgery-related morbidity. Results: Of the 204 patients included, 75 (36.8%) underwent ≤4 NAC cycles and 129 (63.2%) ≥5 NAC cycles. Characteristic data were similar in the two groups. Five-year OS was 35.0 and 25.8%, respectively. This difference was non-significant [HR = 1.06 (0.70-1.59), p = 0.79]. We also found no differences in PFS or morbidity between the two groups. Conclusions: The number of NAC cycles does not seem to play a role in the OS of patients with advanced ovarian cancer. Further evidence and prospective data are needed to assess the value of a high/low number of NAC cycles among these patients.

Revue généraleLe dépistage précoce du cancer du col est-il justifié ?Is early cervical cancer screening justified?

Pap smear screening of women under 25 years old remains controversial. No randomized study exists on this topic. The perception of individual benefit often prevails, although there is no proof of effectiveness and no demonstrated risk-benefit ratio. A review of published studies - taking into account epidemiological data, effectiveness of screening of young women, adverse medical outcomes and costs - suggests that there are more arguments against screening before 25 than in favour of it.

Le dépistage précoce du cancer du col est-il justifié ?

Pap smear screening of women under 25 years old remains controversial. No randomized study exists on this topic. The perception of individual benefit often prevails, although there is no proof of effectiveness and no demonstrated risk-benefit ratio. A review of published studies - taking into account epidemiological data, effectiveness of screening of young women, adverse medical outcomes and costs - suggests that there are more arguments against screening before 25 than in favour of it.

Transvaginal Resection of an Infected Sacrocolpopexy Mesh by Single-Port Trocar

STUDY OBJECTIVE Laparoscopy using a single port improves morbidity while keeping the same level of requirement. This technique has been evaluated in gynecology for salpingectomy, ovarian surgery, and hysterectomy. Here, the authors illustrate a new use of a single port using the transvaginal approach. DESIGN Case report (Canadian Task Force classification III). SETTING Tertiary referral center in Strasbourg, France. PATIENT Woman age 59 years. INTERVENTION Single-port platform used in the transvaginal approach for resection of sacrocolpopexy mesh. The local institutional review board approved the video. MEASUREMENTS AND MAIN RESULTS A 59-year-old woman suffering from insulin-dependent diabetes and a tobacco user had 2 laparoscopic sacrocolpopexies for recurrent rectocele, the first in 2007 and the second in 2012. The sequences were marked by mesh erosion and granuloma in the vagina, requiring its surgical excision in 2016. The patient was then symptomatic, with an increasingly foul-smelling vaginal discharge with recurrent mesh erosion. Magnetic resonance imaging showed an abscess formation along the length of the mesh to the promontory. The patient then underwent surgery, realized under probabilistic antibiotic therapy, consisting of complete excision of the sacrocolpopexy mesh by the transvaginal approach. After putting the single-port trocar (GelPoint; Applied Medical, Rancho Santa Margarita, CA) into the vagina and obtaining distension with the insufflator (AirSeal; Conmed, Utica, NY), classic laparoscopic instruments were introduced by the single-port trocar. The mesh was entirely resected in the retroperitoneal space. Mesh was again used because the exposed space is almost always surrounded by loose granulation tissue that facilitates dissection and also prevents injury to adjacent structures such as bladder, rectum, and peritoneum. Moreover, the opening of adjacent structures will manifest gas leaks and, consequently, loss of the pneumovagina. At the end of procedure, the vagina is not closed to permit optimal drainage with a multitubular drain in the dissection space. The surgery lasted 60 minutes. The mesh excision was completed with relative ease, and there was no blood loss. Bacteriologic examination revealed the presence of Streptococcus anginosus, Klebsiella pneumoniae, and Bacteroides fragili. The operating suites were simple with great cicatrization after 6 weeks. The principal difficulties of this surgery were obtaining a good seal by the creation of cutaneous sutures. Finally, there are less conflicts between the instruments inside the single-port trocar used in transvaginally because of a more limited dissection space. Indeed, the rate of mesh erosion reached 2.4% and, in case of infection, justifies this excision. CONCLUSION The transvaginal use of a single-port trocar represents a good alternative, allowing easy resection of the sacrocolpopexy mesh while remaining in the retroperitoneal space.

Risk of malignancy on suspicion of polyps in menopausal women

Improved performances in gynaecological ultrasonography have enabled an increasing number of often asymptomatic endometrial polyps to be detected. Most of these polyps are removed surgically, as a precautionary measure, so as not to miss a case of endometrial cancer. Nonetheless, this management strategy is based solely on the sonographers judgement and a number of these operations, which are probably of no benefit, could be avoided. In order to do so, risk factors for malignancy need to be identified. OBJECTIVE Estimate the prevalence of lesions in menopausal patients with a pre-operative diagnosis of endometrial polyp. Establish risk factors for malignancy. STUDY DESIGN This is a single-centre retrospective study. Enrolment criteria were menopausal patients aged over 45 who had undergone hysteroscopic resection of a polyp. Pre-op diagnosis was made either by ultrasonography or diagnostic hysteroscopy. Malignant lesions included cancers and atypical hyperplasia. Benign lesions consisted of simple polyps, non-atypical simple hyperplasia and non-atypical complex hyperplasia. Risk factors studied were existing abnormal uterine bleeding, endometrial thickness, personal or first-degree family history of gynaecological cancer (breast, cervix, endometrium, ovary) and age on diagnosis. RESULTS 631 patients were enrolled of whom 30 presented a malignant disorder (4.75%); 579 patients (91.76%) presented a simple polyp, 11 a non-atypical simple hyperplasia (1.74%) and 11 a non-atypical complex hyperplasia (1.74%). On univariate analysis age alone proved to be statistically significant (OR 1.05; 95%CI=[1.02-1.09] p<0.01), with a threshold of 59 years of age on the ROC curve. On multivariate analysis, factors predictive of a malignant lesion were age (OR=1.06; 95%CI [1.02-1.10]), existence of AUB (OR=2.4; 95% CI [1.07-5.42]) and family history (OR=2.88; 95%CI [1.08-7.67]). Neither the univariate nor multivariate model was able to demonstrate a statistically significant relationship with respect to endometrial thickness. The risk of malignancy was 12.3% in patients aged over 59 presenting AUB. For all other subgroups, the risk varied between 2.31 and 3.78%. CONCLUSION The risk of a malignant lesion appears to be high (12%) in menopausal patients aged over 59 presenting an endometrial polyp detected when there is pre-existing AUB. In this situation, hysteroscopic resection of endometrial polyps should therefore be routinely proposed. For other patients, the risk of a malignant lesion is low but not insignificant, standing at about 3%. Each patient record should therefore be discussed on an individual case basis, taking into consideration the patients pre-existing conditions, after providing clear and appropriate information.

Contents Vol. 91, 2016

A.B. Benson, Chicago, Ill. A. Chang, Singapore A.L. Cheng, Taipei J.F. Cleary, Madison, Wis. M. Dietel, Berlin P. Dufour, Strasbourg M.S. Ernstoff, Buffalo, N.Y. M.G. Fakih, Duarte, Calif. J.J. Grau, Barcelona H. Gronemeyer, Illkirch D.F. Hayes, Ann Arbor, Mich. C.S. Johnson, Buffalo, N.Y. M.J. Kelley, Durham, N.C. L. Kumar, New Delhi P.J. Loehrer, Indianapolis, Ind. J.R. Marshall, Buffalo, N.Y. S. Monfardini, Milan R. Nagler, Haifa R. Ohno, Nagoya B. Pestalozzi, Zurich H.M. Pinedo, Amsterdam E.A. Repasky, Buffalo, N.Y. A. Semczuk, Lublin E.F. Smit, Amsterdam C.N. Sternberg, Rome R. Stupp, Zurich M.S. Tallman, New York, N.Y. S. Tanaka, Hiroshima M. Tian, Houston, Tex. D.L. Trump, Buffalo, N.Y. T. Wiegel, Ulm W. Yasui, Hiroshima H. Zhang, Hangzhou City Editor-in-Chief