La grossesse et l'accouchement chez la femme de plus de 40 ans, en fonction de la parité (étude sur 322 cas à l'hôpital Foch de Suresnes)

Les grossesses tardives sont devenues un sujet de préoccupation dans les pays occidentaux du fait de leur constante augmentation depuis plus de 20 ans, de leur réputation à haut risque et de leur proportion de primipares croissante (20% environ). Pour évaluer les risques que pouvait engendrer l âge maternel >= à 40 ans sur la grossesse, l accouchement et le nouveau-né, nous avons étudié les dossiers des 322 femmes ayant accouché après 40 ans, en les comparant à ceux des 7143 femmes de moins de 40 ans, entre 2004 et 2006 à la maternité de l hôpital Foch. Nous avons observé une augmentation significative mais faible de diabète gestationnel, d hypertension artérielle gravidique, de prééclampsie, et une augmentation plus nette de césarienne, sans explication médicale évidente. Ces césariennes arbitraires sont le reflet de l appréhension des médecins et des patientes face aux grossesses tardives, et remettent en cause le principe de précaution du fait du risque chirurgical pour la mère.ST QUENTIN EN YVELINES-BU (782972101) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Individualized prophylactic neck irradiation in cN0 head and neck cancer patients based on sentinel lymph node(s) identification: definitive results of a prospective phase I-II study.

This prospective, non-randomized, interventional phase I-II study investigated the individualization of the elective node irradiation in clinically N0 (cN0) head and neck squamous cell carcinoma (HSNCC) by sentinel lymph node (SLN) mapping with SPECT/CT and its impact on tumor control and radiation-related toxicity. Forty-four cN0 HNSCC patients treated with definitive (chemo-)radiotherapy were imaged with SPECT/CT after 99mTc nanocolloid injection around the tumor. The neck levels containing up to the four hottest SLN were selected for prophylactic irradiation (CTVn-LS). A comparative virtual planning was performed with the selection of neck levels based on the current international guidelines (CTVn-IG). The regional control was monitored in function of the selected volume. Dosimetric data to the organs-at-risk (OAR) were compared between both plans. Normal tissue complication probability (NTCP) rates were derived for xerostomia, dysphagia and hypothyroidism to predict the clinical benefit and correlated to quality of life (QoL) assessments at 6 months. Sixteen percent of patients presented unpredicted lymphatic drainage and 48% drained unilaterally. CTVn-LS were smaller than the CTVn-IG by a factor of two (p < 0.0001). After a median follow-up of 46 months, only 1 patient experienced a regional relapse in a non-irradiated area. Significant median dose reductions to OAR were observed, particularly to contralateral salivary glands in patients with unilateral drainage [14.6 Gy-28.1 Gy] and to the thyroid gland in all patients [22.4 Gy-48.9 Gy]. Median NTCP reductions were observed for xerostomia [0.3%-13.7%], dysphagia [1.7%-10.8%] and hypothyroidism [14.0%-36.1%]. QoL at 6 months was improved, particularly in patients irradiated unilaterally. Neck SLN mapping with SPECT/CT individualizes and reduces the elective nodal target volumes without compromising the regional control. The NTCP rates were reduced and favorable QoL were observed in all patients, particularly in case of unilateral irradiation