Curative pelvic exenteration for recurrent cervical carcinoma in the era of concurrent chemotherapy and radiation therapy. A systematic review

International audienceOBJECTIVE: Pelvic exenteration requires complete resection of the tumor with negative margins to be considered a curative surgery. The purpose of this review is to assess the optimal preoperative evaluation and surgical approach in patients with recurrent cervical cancer to increase the chances of achieving a curative surgery with decreased morbidity and mortality in the era of concurrent chemoradiotherapy. METHODS: Review of English publications pertaining to cervical cancer within the last 25 years were included using PubMed and Cochrane Library searches. RESULTS: Modern imaging (MRI and PET-CT) does not accurately identify local extension of microscopic disease and is inadequate for preoperative planning of extent of resection. Today, only half of pelvic exenteration procedures obtain uninvolved surgical margins. CONCLUSION: Clear margins are required for curative pelvic exenterations, but are poorly predictable by pre-operative assessment. More extensive surgery, i.e. the infra-elevator exenteration with vulvectomy, is a logical surgical choice to increase the rate of clear margins and to improve patient survival following surgery for recurrent cervical carcinoma

Application des recommandations dans la prise en charge du cancer de l’endomètre en pratique clinique. Étude rétrospective bretonne

National audienceObjective - To assess the use of French Cancer Institute recommendations for the diagnosis and treatment of endometrial cancer. Methods - Retrospective observational study involving 137 patients with endometrial cancer between 2011 and 2013. Results - Both MRI and pathological assessment with correct report as recommended were used for 66.4% of patients with endometrial cancer. For patients with correct preoperative assessment, 44.9% of patients were uncorrectly classified and upgraded on final pathological analysis of hysterectomy concerning lymph node involvement risk. These patients did not have confident surgical assessment, according this risk. Conclusion - To improve relevance of preoperative assessment in endometrial cancer, radiological and pathological expertise is required. However, even performed optimally, preoperative assessment does not allow correct risk stratification of lymph node involvement in endometrial cancer. This ineffective stratification leads to propose sentinel lymph node biopsy with hysterectomy in case of preoperative low risk endometrial cancer assessment

Time to revise classification of phyllodes tumors of breast? Results of a French multicentric study

OBJECTIVE: To assess prognostic factors of recurrence of phyllodes tumors (PT) of the breast. METHODS: We performed a retrospective, multicentric cohort study, including all patients who underwent breast surgery for grade 1 (benign), 2 (borderline) or 3 (malignant) PT between 2000 and 2016 in five tertiary University hospitals, diagnosed according to World Health Organisation classification. RESULTS: 230 patients were included: 144 (63%), 60 (26%) and 26 (11%) with grade 1, 2 and 3 PT, respectively. Recurrence occurred in 10 (7%), 7 (12%) and 5 (19%) patients with grade 1, 2 and 3 PT, respectively. In univariate analysis, moderate to severe nuclear stromal pleomorphism (HR 8.00 [95% CI: 1.65-38.73], p < 0.009) was correlated with recurrence in all groups including grade 1 (HR 14.3 [95% CI: 1.29-160], p = 0.031). In multivariate analysis, surgical margin >5 mm, (HR 0.20 [95% CI: 0.06-0.63], p = 0.013) were significantly correlated with less recurrence in all PT grades. For grade 1 PT, there was also significantly less recurrence with surgical margin >5 mm, (HR 0.09 [95% CI: 0.01-0.85], p = 0.047) in multivariate analysis. CONCLUSION: The surgical margin should be at least 5 mm whatever the grade of PT. Moderate to severe nuclear stromal pleomorphism identified a subgroup of grade 1 PT with a higher rate of recurrence. This suggests that the WHO classification could be revised with the introduction of nuclear stromal pleomorphism to tailor PT management

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

Background Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide.Methods A multimethods analysis was performed as part of the GlobalSurg 3 study-a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital.Findings Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3.85 [95% CI 2.58-5.75]; p<0.0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63.0% vs 82.7%; OR 0.35 [0.23-0.53]; p<0.0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer.Interpretation Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised

Recommandations pour la pratique clinique : tumeurs bénignes du sein – Introduction [Clinical practice guidelines: Benign breast tumor – Introduction]

National audienceThe benign breast tumors cover a wide clinical spectrum ranging from stromal-epithelial tumors to breast abscess and epithelial hyperplasia with atypia. Their management has a major medical and economic impact and requires a rational use of paraclinical investigations

Modifications de la stratégie thérapeutique du cancer de l’ovaire en fonction du profil moléculaire [Therapeutic Change According to Molecular Subtype in Ovarian Cancer]

National audienceEpithelial ovarian cancer (EOC) affects 4,500 women a year in France, with a survival of 30% at 5 years. Treatment is based on extensive surgery and chemotherapy. About 15% of CEOs are due to genetic mutations, such as mutation in BRCA 1 and 2. Four histological subtypes are described (serous, endometrioid, mucinous, clear cells), corresponding to different ways of carcinogenesis and distinct molecular mutations. High-grade serous EOC has mutation of the BRCA genes in 20-30% of cases (inherited or somatic). This mutation cause a deficit in homologous recombination DNA repair in case of double strand break, allowing greater sensitivity to platinum salts and the use of inhibitors of PARP, a protein involved in the repair of single strand breaks of DNA. PARP inhibitors showed efficacy in patients mutated BRCA but this effectiveness remains to be demonstrated in patients without congenital mutation, i.e. BRCAness profile. The BRCAness profile is defined by a tumor having a defect in homologous recombination DNA repair (not limited to BRCA mutation). Its molecular definition is still not consensual but is necessary for a theranostic approach with PARP inhibitors. Gene expression analyses have identified four subgroups of high-grade serous EOC: mesenchymal, proliferative, differentiated and immunoreactive. These four subtypes, not mutually exclusive, are not yet used in clinical routine

L’exentération pelvienne curative en cas de récurrence d’un cancer du col de l’utérus à l’ère de la radio-chimiothérapie concomitante : revue de la littérature

National audienc