Fundamentos de la biopsia del ganglio centinela en el cáncer de mama

La linfadenectomía axilar es el método clásico para informarnos del estado de los ganglios axilares en el cáncer de mama. Sin embargo, al incorporarse el screening mamográfico, los tumores diagnosticados en la actualidad son de tamaño reducido. Por lo tanto, el porcentaje de pacientes en las cuales esperamos que exista afectación axilar es muy bajo en la actualidad. La linfadenectomía axilar no esta exenta de morbilidad; afecta al 80% de las pacientes sometidas a resección axilar niveles I y II. En el caso de que exista enfermedad a nivel axilar, esta morbilidad es aceptable y se compensa por el beneficio que la paciente obtiene al reducirse la masa tumoral; no obstante, en los casos en los que no existe afectación de los ganglios axilares esta morbilidad es inaceptable. La biopsia del ganglio centinela permite la resección y estudio de un único ganglio axilar con un mínimo porcentaje de falsos negativos, y una morbilidad prácticamente inexistente. El estudio sobre el ganglio centinela es más exacto y meticuloso, constituyendo en la actualidad la técnica quirúrgica de elección en pacientes con tumores menores de 3 cm. y sin afectación axilar clínica.Axillary lymph node dissection is the gold standard for detecting axillary disease in breast cancer. Node status remains the most important prognostic factor, and is an important information to make decisions over further treatment. However, both the morbidity associated to this technique, and the fact that, due to mammografic screening, most of the cancer cases nowadays are early cancers that have no axillary metastases, have encouraged investigations towards new surgical approaches. Sentinel node biopsy has been recognized to detect any axillary disease with minimal morbidity and false-negative rates. This technique is routinely indicated for tumors below 3 cm in size, without clinical axillary disease

Detección y tipificación mediante biología molecular del virus del papiloma humano en muestras genitales

Últimamente se ha observado un notable incremento de la infección por el virus del papiloma humano (VPH), y se ha confirmado la relación etiológica entre ciertos genotipos del VPH y el cáncer genital. Por ello hemos evaluado la prevalencia de estos virus y su genotipo en muestras genitales, utilizando técnicas de diagnóstico molecular. Procesamos 401 muestras genitales de 281 mujeres y 120 hombres, todos ellos con un diagnóstico compatible con infección por VPH. La detección del virus se realizó por PCR, y las muestras positivas se tipificaron mediante una técnica de microseries de sondas de hibridación que permite detectar los 35 tipos de VPH más frecuentes asociados a mucosas. De los 401 pacientes estudiados, 185 resultaron positivos (46,1%) y en 133 casos sólo se detectó un tipo de VPH. Encontramos que fueron positivos el 41,6% de las mujeres y el 56,7% de los hombres. Se tipificaron en total 260 VPH; 154 resultaron ser de alto riesgo oncogénico e infectaban a 16 hombres (23,5%) y 88 mujeres (75,2%) (p <0.001). El VPH tipo 6 fue el más frecuente, detectado en 64 casos, seguido del VPH 16 en 52 casos. La prevalencia de infección por VPH encontrada ha sido del 46%. Más de la mitad de los pacientes estaban infectados por VPH de alto riesgo. La presencia de VPH de alto riesgo fue significativamente más alta en las mujeres

[Laparoscopic sacrocolpopexy for pelvic organ prolapse: guidelines for clinical practice].

International audienceINTRODUCTION:Open sacrocolpopexy have demonstrated its efficiency in surgical treatment of pelvic organ prolapse with an important backward on a large number of patients. Laparoscopic sacrocolpopexy reproduced the same surgical technique with reduced morbidity and may benefits from the recent development of robotic. Numerous technical variants have been developped around the original procedure but results seems not ever equivalent. Our objectives are to establish practical recommendations issues from the data of the litterature on the various technical aspects of this technique.METHODS:This work leans on an exhaustive lecture of the literature concerning meta analyses, randomized tries, registers, controlled studies and the largest non controlled studies published on the subject. Recommendations were developed by a multidisciplinary workgroup then reread and amended by an also multidisciplinary group of proofreaders (urologists, gynecologists, gastroenterologists and surgeons). The methodology follows at best the recommendations of the HAS with a scientific argument for every question (accompanied with the level of proof, NP) and the recommendations, the officers (In, B, C and agreement of experts) and validated at the end of the phase of review.RESULTS:Surgical treatment of uro-genital prolapse by abdominal route classically associated hystero and anterior vaginopexy on the sacral ligament with a synthethic mesh. There are no argument to systematically associated a posterior vaginopexy to prevent secondary rectocele (level C). The consensual indication of laparoscopic rectopexy is represented by symptomatic rectal prolapse, the anatomical and functional results of which are the best estimated (level C). The surgical treatment of rectocele, elytrocele and enterocele with a posterior vaginopexy is not well estimated (level 3). Thus, it is not possible to conclude on the results of a posterior vaginal fixation with a mesh in these indications (AP). In the absence of colpocèle, the interest brought by the posterior vaginal mesh is not established (level 3). There is no comparative studies which allows to conclude on the type and mode of fixation of the prostheses of sacrocolpopexy. We would only report the most common practices without other conclusion. The anterior mesh is usually fixed upper on the anterior part of uterus cervix and lower on the anterior vaginal wall. These fixations are most of the time made by suture and on the promontory with non absorbable suture. The great majority of the authors recommend to make a peritonisation of prostheses to limit the risk of post-operative occlusion. It is now recommended to use only 2 kind of not absorbable prostheses: type I (macroporous polypropylene) or type III (polyester) and not to use any more prostheses type II (PTFE, Silicone) (level C) because of a high rate of mesh erosion: PTFE (9 %) or Silicone (19%) (level 3). Biological prostheses are no more recommended, because of short and medium-term lower anatomical results (level B). Anatomical and functional results are not stastistically differents between laparotomy and coelioscopy (NP1) but the comparison of tong-term results between both ways is not yet established. Coelioscopy allows significant reduction of blood losses, hospital stay and return to normal activity (level 1). Furthemore, there is a higher level of post-operative complications in laparotomy (level 1). When sacrocolpopexy is indicated, coelioscopy is thus recommended (level B). During coelioscopic sacrocolpopexy, anatomical and functional result have not shown any significance difference when using or no a robotics assistance but real randomised studies does not exist (level 2). In comparison to coelioscopy, robotic seems not to improve post-operative consequences and not to decrease the rate of complications of sacrocolpopexy (level 3). Robotic assistance cannot be yet recommended when a coelioscopic sacrocolpopexy is indicated (rank B).CONCUSION:Sacrocolpopexy using not absorbable meshes allows to cure pelvic organ prolapses with very good results with few complications in terms of prothetic exposure and infection and thus is now considered as the referent prothetic surgical technique in this indication. Thus, it seems very important to establish clear recommendations on the numerous operating technical variants which developed around the original technique. © 2016 Published by Elsevier Masson SAS