Martin Koskas

Infertile Women with Deep and Intraperitoneal Endometriosis: Comparison of Fertility Outcome According to the Extent of Surgery

STUDY OBJECTIVE This study was undertaken to ascertain whether the incidence of spontaneous pregnancy is increased in infertile women with deep and intraperitoneal endometriosis undergoing extensive surgery compared with those undergoing only intraperitoneal surgery. DESIGN Retrospective case control study (Canadian Task Force classification II-1). SETTING University teaching hospital. PATIENTS Infertile women under the age of 40 years with deep and intraperitoneal endometriosis and no other associated major infertility factors. Only patients with at least 1 year of postoperative follow-up were included. INTERVENTIONS Intraperitoneal surgery only (group 1) or extensive surgery (group 2) according to a shared decision-making approach. MEASUREMENTS AND MAIN RESULTS Among the 34 women in group 1, 6 became pregnant, compared with 8 of the 41 women who had extensive surgery (12-month cumulative probabilities, 24.8% and 11.4%, respectively, and 24-month cumulative probabilities, 24.8% and 23.2%, respectively; p = .82). Perioperative surgical complication rate was higher in group 2 (6/41 versus 0/34; p = .02). CONCLUSION Extensive surgery for intraperitoneal and deep endometriosis in infertile women does not modify global fertility outcome but is associated with a higher complication rate.

Office Hysteroscopy for Infertility: A Series of 557 Consecutive Cases

Objective. To study incidence of abnormal hysteroscopic findings according to age. Methods. We retrospectively studied 557 consecutive office hysteroscopies in patients referred for incapacity to conceive lasting at least 1 year or prior to in vitro fertilization. Rates of abnormal findings were reviewed according to age. Results. In 219 cases, hysteroscopy showed an abnormality and more than a third of our population had abnormal findings that could be related to infertility. Rates of abnormal findings ranged from 30% at 30 years to more than 60% after 42 years. Risk of abnormal finding was multiplied by a factor of 1.5 every 5 years. Conclusion. Our data are an additional argument to propose office hysteroscopy as part of first-line exams in infertile woman, regardless of age.

Safety of uterine and/or ovarian preservation in young women with grade 1 intramucous endometrial adenocarcinoma: a comparison of survival according to the extent of surgery

OBJECTIVE To compare the survival of patients with grade 1 intramucous endometrial adenocarcinoma according to the extent of surgery. DESIGN Retrospective cohort study. SETTING Not applicable. PATIENT(S) A cohort of 489 patients who were 40 years of age or younger with grade 1 intramucous endometrial adenocarcinoma. INTERVENTION(S) The patients were divided into the following three groups: 101 patients who underwent uterine preservation, 184 patients who underwent ovarian preservation, and 204 patients who underwent hysterectomy with oophorectomy. MAIN OUTCOME MEASURE(S) The demographics and survival rates were compared. RESULT(S) In the multivariate analysis, no factors were associated with ovarian preservation. In the multivariate analysis, the factors that were associated with uterine preservation were a later year of diagnosis and young age. In a multivariate Cox model, ovarian and uterine preservation had no effect on either cancer-specific or overall survival. CONCLUSION(S) In patients with grade 1 intramucous endometrial adenocarcinoma, uterine and ovarian preservation were not associated with an increase in cancer-related mortality. Longer follow-up is needed to confirm the safety of a conservative approach toward the ovaries and/or the uterus.

L1CAM expression in endometrial carcinomas: an ENITEC collaboration study

Background:Identification of aggressive endometrioid endometrial carcinomas (EECs) and non-endometrioid carcinomas (NEECs) is essential to improve outcome. L1 cell adhesion molecule (L1CAM) expression is a strong prognostic marker in stage I EECs, but less is known about L1CAM expression in advanced-stage EECs and NEECs. This study analyses L1CAM expression in a clinically representative cohort of endometrial carcinomas.Methods:The expression of L1CAM was immunohistochemically determined in 1199 endometrial carcinomas, treated at one of the European Network for Individualized Treatment of Endometrial Cancer (ENITEC) centres. Staining was considered positive when >10% of the tumour cells expressed L1CAM. The association between L1CAM expression and several clincopathological characteristics and disease outcome was calculated.Results:In all, L1CAM was expressed in 10% of the 935 stage I EECs, 18% of the 160 advanced stage EECs, and 75% of the 104 NEECs. The expression of L1CAM was associated with advanced stage, nodal involvement, high tumour grade, non-endometrioid histology, lymphovascular space invasion, and distant recurrences in all cases, and with reduced survival in the EECs, but not in the NEECs.Conclusions:The expression of L1CAM is a strong predictor of poor outcome in EECs, but not NEECs. It is strongly associated with non-endometrioid histology and distant spread, and could improve the postoperative selection of high-risk endometrial carcinomas. The value of L1CAM expression in the preoperative selection of high-risk endometrial carcinomas should be studied.

Can rectal endoscopic sonography be used to predict infiltration depth in patients with deep infiltrating endometriosis of the rectum

To evaluate the diagnostic accuracy of rectal endoscopic sonography (RES) in the prediction of the infiltration depth of rectal endometriosis and to ascertain whether RES could be used to choose between segmental bowel resection and a more conservative approach, such as shaving or discoid resection.

Independent external validation of radiotherapy and its impact on the accuracy of a nomogram for predicting survival of women with endometrial cancer

OBJECTIVE To externally validate and assess the impact of radiotherapy on the accuracy of a nomogram for predicting overall survival of women with endometrial cancer. METHODS Using data from the Surveillance, Epidemiology, and End Results (SEER), we assessed the concordance indexes, the discrimination and the calibration provided by a nomogram for predicting overall survival. Patients were grouped into deciles based on their survival predictions, and the three-year overall survival in each group was compared with the mean predicted probability. RESULTS Between 1988 and 2006, 64,023 patients were analyzed and divided into two groups: 14,323 patients with adjuvant radiotherapy and 49,700 patients without adjuvant radiotherapy. Among the whole population, predicted and observed three-year overall survivals were 85.2% and 85.6% (+/-0.1%) respectively. In patients with adjuvant radiotherapy, overall survivals were 81.0% and 83.1% (+/-0.3%) and in patients without adjuvant radiotherapy, they were 86.5% and 86.3% (+/-0.2%) respectively. The concordance indexes for the whole population, in patients with radiotherapy and in patients without radiotherapy were 0.811 (+/-0.004), 0.751 (+/-0.009) and 0.803 (+/-0.006) respectively. The mean and maximal errors in patients with radiotherapy were 2.1% and 4.0% and in patients without radiotherapy 2.3% and 8.1%. CONCLUSIONS The nomogram can accurately predict three-year overall survival, whether patients undergo adjuvant radiotherapy or not. The nomogram has an improved individual discrimination when compared with the 1988 and the 2009 staging systems for endometrial cancer. It may be useful in the information processed for patients and in building surveillance timing.

Staging for endometrial cancer: The controversy around lymphadenectomy – Can this be resolved?

Endometrial cancer remains the most common malignancy of the female genital tract. Lymph node metastasis is one of the most important prognostic factors, and stratification into pelvic lymph node invasion (stage IIIC1) and para-aortic lymph node invasion (stage IIIC2) improved the predictive value of the 2009 International Federation of Gynecology and Obstetrics (FIGO) classification. Radiological examination methods such as magnetic resonance imaging and positron emission tomography-computed tomography do not have good-enough sensitivity to avoid lymphadenectomy for the assessment of lymph node invasion. Prediction scores are becoming increasingly valuable to exclude lymph node metastasis in low-risk groups, and biomarkers could help to identify patients with high-risk lymph node metastatic probability. The therapeutic role of lymph node dissection remains a matter of debate. Several end points can be considered to evaluate the opportunity of lymphadenectomy in endometrial cancer. First, we compare survival according to the realization, the extent, and the numbers of nodes removed during lymphadenectomy. Second, we assess the opportunity of lymphadenectomy in order to tailor adjuvant treatment modalities. Third, we analyze the surgical complication rate after pelvic lymphadenectomy.

Improvement of first-trimester ultrasound screening in socially deprived settings through a community-based perinatal network

INTRODUCTION The North Paris community-based Perinatal Network was set up in 2003 to improve the quality of prenatal care in an area surrounding the Bichat Claude Bernard University Hospital characterized by high social deprivation. The aim of this study is to assess the impact of the network on early perinatal care. MATERIALS AND METHODS A retrospective observational study on medical records was conducted over four periods: one year before the setting up of the network (2002), the year the network became operational (2003), and one year (2004) and five years (2008) after implementation. Endpoints were the proportion of women delivered in the institution who underwent first-trimester ultrasound screening and the proportion of nuchal translucency measurements deemed acceptable (image quality score from 4 to 9 according to the Herman scoring system). RESULTS Between 2002 and 2004, substantial improvements were noted in access to first-trimester ultrasound screening (55.8% in 2002, 65.9% in 2003, 71.9% in 2004, P<0.05) and in the quality of nuchal translucency measurement (acceptable measurement over this period, 51.1%, 67.8% and 77.8%, respectively, P<0.001). Five years after network set-up, indicators remained unchanged from those of 2004. The rate of first ultrasound screening performed was 72.1% and the rate of acceptable measurement 71.1%, both non-statistically different from 2004 rates. CONCLUSION This perinatal network seems to be associated with an improvement in early prenatal care. However, the rate of first ultrasound performed remained unsatisfactory and to further improve these indicators, upstream social interventions are needed.

Anti-N-methyl-D-aspartate receptor encephalitis complicating ovarian teratomas: a case report

Anti-N-methyl-D-aspartate receptor encephalitis is an emerging disease that affects young women. Its diagnosis can be delayed because of the neuropsychiatric symptoms in the foreground, but early removal of the associated teratoma improves the prognosis. We report the treatment of a patient with anti-N-methyl-D-aspartate receptor encephalitis that was related to an ovarian teratoma.

Gigantomastia and vulvar lactating adenoma in a patient with myasthenia during pregnancy

We report the association of gigantomastia during pregnancy and a lactating adenoma in ectopic breast tissue of the vulva in a context of myasthenia in a 27-year-old primigravid woman. We discuss the pathophysiologic condition and management of gigantomastia that involves ectopic breast tissue during pregnancy.