Gynécologie Obstétrique Fertilité & Sénologie 

Tumeurs frontières de l’ovaire. Recommandations pour la pratique clinique du CNGOF — Épidémiologie et facteurs de risques de récidive, modalités de surveillance et intérêt d’une chirurgie de clôture

To provide clinical practice guidelines from the French college of obstetrics and gynecology (CNGOF) based on the best evidence available, concerning epidemiology of recurrence, the risk or relapse and the follow-up in case of borderline ovarian tumor after primary management, and evaluation of completion surgery after fertility sparing surgery. English and French review of literature from 2000 to 2019 based on publications from PubMed, Medline, Cochrane, with keywords borderline ovarian tumor, low malignant potential, recurrence, relapse, follow-up, completion surgery. From 2000 up to this day, 448 references have been found, from which only 175 were screened for this work. Overall risk of recurrence with Borderline Ovarian Tumour (BOT) may vary from 2 to 24% with a 10-years overall survival>94% and risk of invasive recurrence between 0.5 to 3.8%. Age<40 years (level of evidence 3), advanced initial FIGO stage (LE3), fertility sparing surgery (LE2), residual disease after initial surgery for serous BOT (LE2), implants (invasive or not) (LE2) are risk factors of recurrence. In case of conservative treatment, serous BOT had a higher risk of relapse than mucinous BOT (LE2). Lymphatic involvement (LE3) and use of mini invasive surgery (LE2) are not associated with a higher risk of recurrence. Scores or Nomograms could be useful to assess the risk of recurrence and then to inform patients about this risk (gradeC). In case of serous BOT, completion surgery is not recommended, after conservative treatment and fulfillment of parental project (grade B). It isn't possible to suggest a recommendation about completion surgery for mucinous BOT. There is not any data to advise a frequency of follow-up and use of paraclinic tools in general case of BOT. Follow-up of treated BOT must be achieved beyond 5 years (grade B). A systematic clinical examination is recommended during follow-up (grade B), after treatment of BOT. In case of elevation of CA-125 at diagnosis use of CA-125 serum level is recommended during follow-up of treated BOT (grade B). When a conservative treatment (preservation of ovarian pieces and uterus) of BOT is performed, endovaginal and transabdominal ultrasonography is recommended during follow-up (grade B). There isn't any sufficient data to advise a frequency of these examinations (clinical examination, ultrasound and CA-125) in case of treated BOT. Risk of relapse after surgical treatment of BOT depends on patients' characteristics, type of BOT (histological features) and modalities of initial treatment. Scores and nomogram are useful tools to assess risk of relapse. Follow-up must be performed beyond 5 years and in case of peculiar situations, use of paraclinic evaluations is recommended.

Facteurs prédictifs d’une résection hystéroscopique des fibromes sous-muqueux en deux temps. Étude rétrospective unicentrique

Hysteroscopic resection of submucosal fibroids is an effective technique to reduce menometrorrhagia and improve fertility. Identifying predictors of two-step resections is essential to optimize preoperative counseling and surgical planning. The objective of this retrospective study was to assess predictive factors previously reported in the literature. We analyzed 106 patients who underwent hysteroscopic fibroid resection at Lyon Sud University Hospital between January 2019 and January 2024. Fibroid size was the only factor significantly associated with the need for a two-step resection. For fibroids ≥3cm in diameter, the odds ratio for requiring a second procedure was 13.3, with the risk increasing from 4.1% to 36.4%. Complication rates and fluid deficit were also higher in two-step resections. Fibroid size appears to be the main predictor of two-step hysteroscopic resection. This finding has direct clinical relevance, as it allows for more accurate preoperative counseling of patients, more than one-third of whom may require a second intervention. Prospective multicenter studies are needed to confirm these results.

Modalités préférées des femmes à la Réunion pour le dépistage du cancer du col de l’utérus par prélèvement vaginal

Since the introduction of HPV testing as a first-line screening method for women aged 30 and over, vaginal sampling (VS) by a healthcare professional or self-sampling (SS) is now possible for women who have not responded to the organized screening program using cervical uterine sampling. The aim of this study was to understand the choices made by a sample of women from La Reunion would like to perform their VS, and the content of the instructions they would like to receive. We conducted a cross-sectional descriptive study using a single-answer questionnaire. Patients were either interviewed in doctors' office or offered the possibility to answer an online questionnaire. We included women aged 30 to 65 in La Reunion who were concerned by CC screening. We compared the answers of women who were up to date with their screening with those of women who were not. We included 202 women. The study showed that 64.9% of patients wished to collect the VS kit from a healthcare professional, 80.8% wished to perform SS and 52.5% wished to return it to the laboratory. The preferred language of the instruction was French, with pictures and drawings for 48.5% of patients. There was no significant difference between the answers of women who were up to date with their screening and those who were not. In a sample of women eligible for CC screening in La Reunion, the preferred methods for CC screening were to collect the PV kit from a healthcare professional, perform the SS at home and then return it to the laboratory. These responses differed from other studies. A feasibility study on a part of La Reunion's eligible population for CC screening would enable us to assess the feasibility and generalizability of a screening modality based on SS.

Mortalité maternelle de causes indirectes (hors AVC, maladies cardiovasculaires et infections) en France 2016–2018

Place du ganglion sentinelle dans la prise en charge du cancer de l’ovaire de stade précoce : revue de la littérature

The initial management of early-stage ovarian cancer consists of staging surgery including pelvic and para-aortic lymphadenectomy. The use of the sentinel lymph node (SLN) procedure in this setting may decrease the morbidity associated with this surgery. The objective of this review was to evaluate the feasibility of the SLN procedure in ovarian cancer diagnosed at an early stage by comparing the different techniques used and their accuracy. A systematic literature search was performed on PubMed and ClinicalTrials.gov for articles in English or French about the SLN technique in ovarian cancer. Ten studies were included in the analysis, with a total of 179 patients. The main tracers used were Technetium-99m, indocyanine green, and patent blue, and the most common site of injection was the proper ovarian and unfundibulopelvic ligaments. The overall detection rate was 87.7%. Of the small number of cases of lymph node metastasis reported, the SLN procedure had a sensitivity of 90.9% and a negative predictive value of 98.8%. The sentinel node procedure appears to be feasible and safe and could be reliable in determining the lymph node status of patients with early-stage ovarian cancer.

Goître ovarien ou struma ovarii : une tumeur ovarienne rare à ne pas méconnaitre

Tumeurs frontières de l’ovaire. Recommandations pour la pratique clinique du CNGOF – Biopathologie des tumeurs frontières de l’ovaire

Ovarian borderline tumors (OBT) represent a heterogeneous group of lesions with specific management for each histological subtype. Thus, the correct histological diagnosis is mandatory. References were searched by PubMed from January 2000 to January 2018 and original articles in French and English literature were selected. OBT should be classified according to the last WHO classification. Any micro-invasion (foci<5mm) or microcarcinoma (foci<5mm with nuclear atypia and desmoplastic stromal reaction) should be indicated in the pathology report. In case of serous OBT, variants (classical or the micropapillary/cribriform) should be indicated (grade C). The peritoneal implants associated with OBT, should be classified as invasive or noninvasive, according to the extension into the underlying adipous tissue. If no adipous tissue is seen the term undetermined should be used (grade B). In case of mucinous OBT bilateral and/or with peritoneal implants or peritoneal pseudomyxoma a search for primitive gastrointestinal, appendiceal or biliopancreatic tumor should be performed (grade C). In case of OBT, a thorough sampling of the tumor is recommended, with 1 block/cm and 2 blocks/cm in case of mucinous OBT, serous OBT micropapillary variant, OBT with intraepithelial carcinoma or/and micro-invasion. Peritoneal implants should be examined in toto. Omentum without macroscopic lesion should be sampled in 4 to 6 blocks (grade C). In case of ovarian cyst suspicious for OBT, fine needle aspiration is not recommended (grade C). In case of ovarian tumor suspicious for OBT, intraoperative examination should be performed by a gynecological pathologist (grade C).

Stratégie thérapeutique et place de la chirurgie carcinologique programmée pendant la pandémie de COVID-19 : À propos d’un cas

Évaluation rétrospective de la pertinence des soins dans la prise en charge des tumeurs ovariennes présumées bénignes

The relevance of care is defined by the right act, for the right patient, at the right time. We were interested in the relevance of the management of presumed benign ovarian tumors before and after the release of the CNGOF guidelines 2013 (French guidelines). This is a retrospective observational study conducted at the University Hospital in Strasburg France from 01/01/2013 to 31/12/2017 including all patients treated for a presumed benign ovarian cyst. We were interested in the diagnostic approach: relevance of the prescribed imaging and the use of CA 125 dosage, in the therapeutic approach: the relevance of the technique used as well as the relevance of the surgical indication. We compared our practices between 2013 and 2017 for these same items. We included 682 cysts for 621 patients, the imaging performed was relevant in 55% of cases, not relevant but justified in 25% and irrelevant in 20%. The CA 125 assay or its absence of assay was relevant in 84% of cases. The surgical technique was relevant in 67% of cases and not relevant but justified in 29%. With a significant improvement 7.1% in 2013 of irrelevant against 0.9% for the year 2017. The surgical indication was relevant in 72% of cases, not relevant but justified in 20% and irrelevant in 2.7%. The analysis of the relevance of care allows an evaluation of our practices. Professional recommendations can have an impact on the quality of care.

Comment je fais… simplement la recherche du ganglion sentinelle inguinal lors d’un cancer vulvaire ?

Tumeurs frontières de l’ovaire. Recommandations pour la pratique clinique du CNGOF – Contraception hormonale et THM/THS après tumeur frontière de l’ovaire

Contraceptive options and menopause management are frequent clinical issues among women previously treated for a borderline ovarian tumour (BOT). To synthesize knowledge on BOT and risk related to hormonal contraception and to menopausal hormone therapy (MHT), and to propose recommendations on contraception and MHT after BOT treatment. Systematic review of the literature about hormonal contraception and BOT and on MHT and BOT was conducted on PubMed/Medline and the Cochrane Library. There are no data concerning hormonal contraception after BOT. Current or previous oral contraception is associated with a trend towards decreased risk of serous BOT. Mucinous BOT risk is not or slightly decreased by oral contraception. Hormonal contraception is thus not contraindicated in women previously treated for a BOT (grade C). MHT is associated with a trend towards increased risk of serous BOT. No relation was found between MHT and risk of mucinous BOT. Serous BOTs with high-risk histological criteria (micropapillary pattern, stromal microinvasion or peritoneal implants) are at high-risk of invasive potentially hormone-sensitive recurrence. Hence, caution is needed in the decisions of using MHT after serous BOT with one of these high-risk histological criteria, and MHT should be discussed on a case to case basis. MHT can be prescribed without restriction in women previously treated for mucinous and serous BOT without high-risk histological criteria (grade C). Hormonal contraception can be used after BOT. The histological characteristics of the tumour must be taken into account when deciding on the use of HRT/THM.

Tumeurs frontières de l’ovaire. Recommandations pour la pratique clinique du CNGOF — prise en charge chirurgicale des stades avancés des tumeurs frontières de l’ovaire

To evaluate the surgical management of borderline ovarian tumors (BOT) in the framework of recommendations for clinical practice made by the National College of Obstetricians and Gynecologists (CNGOF) METHODS: This is a comprehensive review of the literature on the advanced stages of BOT. Bibliographic selection was conducted in PubMed from 2007 to 2019 inclusive, selecting publications in English and French. Articles were selected on the basis of the title, then the abstract and finally the full article. The levels of evidence of the studies were defined according to the scale proposed by the High Authority of Health (HAS). By analogy with epithelial ovarian cancer, in case of preoperative suspicion or after a postoperative diagnosis of advanced BOT, the patient must be referred to an expert centre in ovarian cancer (gradeC). There is no data from the literature to conclude that a hysterectomy should be performed routinely, however, the goal in the advanced stages of BOT is no tumor residue (gradeC). In advanced stages of BOT, systematic lymphadenectomy is not recommended, but excision of suspected lymph node on preoperative and intraoperative evaluation, for curative purposes, may be discussed to obtain no residual disease (gradeC). It is recommended to describe peritoneal carcinomatosis before any excision as well as tumor residues at the end of surgery (grade B). The use of a peritoneal carcinomatosis score to evaluate tumor burden such as the "Peritoneal Carcinosis Index" (PCI) is recommended (gradeC). For advanced stages of BOT, a conservative treatment with at least the preservation of the uterus and an ovarian fragment in a patient wishing a pregnancy may be proposed after Multidisciplinary Concertation Meeting (GradeC). Contralateral ovary biopsy is not recommended in advanced stage BOT (GradeC) but restaging surgery associated with removal of all tumor lesions is recommended when not performed initially (GradeC). It is not possible to make a recommendation on chemotherapy indication in advanced stages even with invasive implants. The weakness of the literature and the retrospective nature of BOT advanced stage studies limit the grade of the recommendations.

Tumeurs frontières de l’ovaire. Recommandations pour la pratique clinique du CNGOF — Aspects épidémiologiques et facteurs de risque

The incidence (rate/100,000) of BOT gradually increases with age from 15-19 years of age and peaks at nearly 4.5 cases/100,000 for the 55-59 year age group (NP3). In the presence of a benign ovarian mass, the standardized risk ratio of serous and mucinous BOT is 1.69, (95% CI 1.39-2.03) and 1.75, (95% CI 1.45-2.10), respectively (NP2). At diagnosis, a median age of diagnosis of OFA is 46 years, unilateral forms (79.7% of cases) are predominant compared to cancers (45.3%) (<0.001) and FIGO I stages represent nearly 63.7% of cases (NP3). The 5-year survival rates for FIGO I, II, III, IV stages are: 99.7% (95% CI: 96.2-100%), 99.6% (95% CI: 92.6-100%), 95.3% (95% CI: 91.8-97.4%), 77.1% (95% CI: 58.0-88.3%), respectively (NP3). Survivors at 5 years for serous and mucinous tumours are 99.7% (95% CI: 99.2-99.9%), 98.5% (95% CI: 96.9-99.3%), respectively (NP3). An epidemiological association exists between personal BOT risk and: (1) a familial history of BOT/certain cancers (pancreas, lung, bone, leukemia) (NP3), (2) a personal history of benign ovarian cyst (NP2), (3) a personal history of pelvic inflammatory disease (IGH), (4) the use of intrauterine device levonorgestrel (NP3), (5) the use of oral contraceptive pills (NP3), (6) multiparity (NP3), (7) hormone replacement therapy (NP3), (8) high consumption of coumestrol (NP4), (9) medical treatment of infertility with progesterone (NP3), (10) non-steroidal anti-inflammatory drug (NSAID). An epidemiological association exists between previous/actual tabacco consumption and the risk of mucinous ovarian BOT (NP2). Relative risk (RR) varies between 2.2 and 2.7, however the relationship is not necessarily a causal one. An epidemiological association exists between overweight/obesity and the risk of serous BOT (NP2). RR varies between 1.2 to 1.8. The high Vitamin D was inversely associated to the risk of serous BOT (NP4). The risk of mucinous BOT was lowered with paracetamol use (OR=0.77; 95% CI: 0.60-0.98) (NP3). However, the relationship between these factors and BOT is not necessarily a causal one and no screening modality can be proposed in the general population (gradeC).

Tumeurs frontières de l’ovaire. Recommandations pour la pratique clinique du CNGOF – Pertinence des marqueurs tumoraux

To evaluate the diagnostic value of serum biomarkers in the management strategy of borderline ovarian tumours (BOT) to make management recommendations. English and French review of literature from 1990 to 2019 based on publications from Pubmed, Medline, Cochrane, with keywords: borderline ovarian tumors, tumour markers, CA125, CA19 9, ACE, CA72 4, TAG72, HE4, ROMA, mucinous, serous, mucinous, endometrioid ovarian tumours, peritoneal implants, recurrence, overall survival, follow-up. Among 1000 references, 400 were selected and only 30 were screened for this work. Literature review: there is low evidence in literature concerning the discriminating value of serum tumour biomarkers (CA125, CA19-9, CEA, CA72-4, HE4) and specific score between presumed benign ovarian tumour/BOT/ovarian cancer (LE4). Serum CA125 antigen is higher in case of serous borderline ovarian tumour (LE4), increase with the tumor height, the FIGO stage, notably in case of serous borderline ovarian tumor. However, a normal value rate of serum CA125 antigen does not rule out a BOT (LE4). The preoperative positivity rate of CA19 9 in case of TFO is relatively lower than that of CA125 and is higher in mucinous TFO. The preoperative rate of serum CA19 9 antigen increases with the tumour height and the FIGO stage (LE4) and are higher in case of mucinous BOT (LE4). Preoperative rates of serum HE4 are not different between histologic type of BOT. A high level of serum biomarkers (CA125) is a predictive factor of peritoneal implants (LE4) and an independent predictive factor of recurrence (CA125) (LE4). no recommendation can be made about the use of serum tumour biomarkers (CA125, CA19-9, CEA, CA72-4, HE4) or specific score in order to distinguish benign ovarian tumor/borderline ovarian tumor/ovarian cancer in case of indeterminate mass. In case of suspicion of mucinous ovarian tumour on imaging, the systematic dosage of serum CA19-9 antigen can be proposed (grade C). In case of an ovarian indeterminate mass on imaging; dosage of serum HE4 and C125 is recommended. If preoperative dosage of serum tumor biomarkers is normal, their systematic dosage is not recommended in the follow-up of BOT (grade C). If preoperative dosage of CA125 is high, the systematic dosage of CA125 is recommended in the follow-up of BOT with no precisions about the rhythm and the duration of the follow-up (grade B).

Tumeurs frontières de l’ovaire. Recommandations pour la pratique clinique du CNGOF – Méthodes et organisation

This text presents organizational and methodological aspects of the development of the French guidelines on the management of borderline ovarian tumours.

Tumeurs frontières de l’ovaire. Recommandations pour la pratique clinique du CNGOF – Grossesse

To determine the place of imaging, tumour markers, type of treatment and surgical route, follow-up, delivery mode, and re-staging in case of BOT during pregnancy, in order to provide guidelines. A systematic bibliographical analysis on BOT during pregnancy was performed through a PUDMED search on articles published from 1990 to 2019 using keywords « borderline ovarian tumour and pregnancy ». Pelvic ultrasound is the gold standard and first-line examination for the detection and characterization of adnexal masses during pregnancy (grade C). Pelvic MRI is recommended from 12 gestational weeks in case of indeterminate adnexal masses and should be concluded by a diagnostic score (grade C). Gadolinium injection should be minimized because of proven risk to the fetus and should be discussed on a case-by-case basis after patient information (grade C). In the absence of data in the literature, it is not possible to recommend the use of any tumour marker for the diagnosis of BOT during pregnancy. In case of a surgical treatment of BOT during pregnancy, there is insufficient evidence to recommend either a cystectomy or an oophorectomy. For BOT, the laparoscopic approach should be preferred during pregnancy if it is feasible (grade C). Surgical route and type of surgery should be chosen after taking into account the tumour size, the obstetrical term, and the subsequent desire for pregnancy, following discussion in a multidisciplinary meeting. In the absence of sufficient data in the literature, it is not possible to make any recommendation on the follow-up of a BOT suspected during pregnancy. There is not enough evidence in the literature to change obstetrical management for delivery in patients with BOT. In case of incomplete staging of a BOT treated during pregnancy, restaging can be discussed as for non-pregnant patients (grade C). The diagnosis of BOT occurring during pregnancy remains rare despite systematic screening of adnexal masses in the first trimester of pregnancy and an increasing maternal age. There is limited data in the literature concerning the management of BOT during pregnancy. All decisions must be taken after discussion in a multidisciplinary meeting.

Tumeurs frontières de l’ovaire. Recommandations pour la pratique clinique du CNGOF – Fertilité

Borderline ovarian tumours (BOT) represent around 15% of all ovarian neoplasms and are more likely to be diagnosed in women of reproductive age. Overall, given the epidemiological profile of BOT and their favourable prognosis, ovarian function and fertility preservation should be systematically considered in patients presenting these lesions. The research strategy was based on the following terms: borderline ovarian tumour, fertility, fertility preservation, infertility, fertility-sparing surgery, in vitro fertilization, ovarian stimulation, oocyte cryopreservation, using PubMed, in English and French. Fertility counselling should become an integral part of the clinical management of women with BOT. Patients with BOT should be informed that surgical management of BOT may cause damage ovarian reserve and/or peritoneal adhesions. Nomogram to predict recurrence, ovarian reserve markers and fertility explorations should be used to provide a clear and relevant information about the risk of infertility in patients with BOT. Fertility-sparing surgery should be considered for young women who wish preserving their fertility when possible. There is insufficient evidence to claim a causal relation between controlled ovarian stimulation (COS) and BOT. However, in case of poor prognosis factors, the use of COS should be considered cautiously through a multidisciplinary approach. In case of infertility after surgery for BOT, COS can be performed without delay, once histopathological diagnosis of BOT is confirmed. There is insufficient consistent evidence that fertility drugs and COS increase the risk of recurrence of BOT after conservative management. The conservative surgical treatment can be associated to oocyte cryopreservation considering the high risk of recurrence of the disease. In women with BOT recurrence in a single ovary and in women with bilateral ovarian involvement when the conservative management is not possible, other fertility preservation strategies are available, but still experimental.

Tumeurs frontières de l’ovaire. Recommandations pour la pratique clinique du CNGOF – Prise en charge thérapeutique des stades précoces

To provide guidelines for clinical practice from the French College of Obstetrics and Gynecology (CNGOF), based on the best evidence available, concerning early stage borderline ovarian tumors (BOT). Bibliographical search in French and English languages by consultation of Pubmed, Cochrane, Embase, and international databases. Considering management of early stage BOT, if surgery is possible without a risk of tumor rupture, the laparoscopic approach is recommended compared to laparotomy (Grade C). In BOT, it is recommended to take all the measures to avoid tumor rupture, including the peroperative decision of laparoconversion (Grade C). In BOT, extraction of the surgical specimen using an endoscopic bag is recommended (Grade C). In case of early stage, uni or bilateral BOT, suspected in preoperative imaging in a postmenopausal patient, bilateral adnexectomy is recommended (Grade B). In cases of bilateral BOT and desire of fertility preservation, a bilateral cystectomy is recommended (Grade B). In case of mucinous BOT and desire of fertility preservation, it is recommended to perform a unilateral adnexectomy (Grade C). In case of endometrioid BOT and desire of fertility preservation, it is not possible to establish a recommendation of treatment choice between cystectomy and unilateral adnexectomy. In case of mucinous BOT at definitive histological analysis in a woman of childbearing age who had an initial cystectomy, surgical revision for unilateral adnexectomy is recommended (Grade C). In the case of serous BOT with definitive histological analysis in a woman of childbearing age who has had an initial cystectomy, it is not recommended to repeat surgery for adnexectomy in the absence of residual suspicious lesion during initial surgery and/or on postoperative imaging (referent ultrasound or pelvic MRI) (Grade C). An omentectomy is recommended for complete initial surgical staging when BOT is diagnosed on extemporaneous analysis or suspected on preoperative radiological elements (Grade B). There is no data in the literature to recommend the type of omentectomy to be performed. If restaging surgery is decided for a presumed early stage BOT, an omentectomy is recommended (Grade B). Multiple peritoneal biopsies are recommended for complete initial surgical staging when BOT is diagnosed on extemporaneous or suspected on preoperative radiological elements (Grade C). In case of restaging surgery for a presumed early stage BOT, exploration of the abdominal cavity should be complete and peritoneal biopsies should be performed on suspicious areas or systematically (Grade C). A primary peritoneal cytology is recommended in order to achieve complete initial surgical staging when BOT is suspected on preoperative radiological elements (Grade C). In case of restaging surgery for presumed early stage BOT, a first peritoneal cytology is recommended (Grade C). For early serous or mucinous BOT, it is not recommended to perform a systematic hysterectomy (Grade C). For early stage endometrioid BOT, and in the absence of a desire to maintain fertility, hysterectomy is recommended for initial surgery or if restaging surgery is indicated (Grade C). For endometrioid-type early stage BOT, if there is a desire for fertility preservation, the uterus may be retained subject to good evaluation of the endometrium by imaging and endometrial sampling (Grade C). In case of surgery (initial or restaging if indicated) for early stage BOT, it is recommended to evaluate the macroscopic appearance of the appendix (Grade B). In case of surgery (initial or restaging if indicated) for early stage BOT, appendectomy is recommended only in case of macroscopically pathological appearance of the appendix (Grade C). Pelvic and lumbar aortic lymphadenectomy is not recommended for initial surgery or restaging surgery for early stage BOT regardless of histologic type (Grade C). In case of BOT diagnosed on definitive histology, the indication of restaging surgery should be discussed in Multidisciplinary Collaborative Meeting. For presumed early stage BOT, it is recommended to use the laparoscopic approach to perform restaging surgery (Grade C). Restaging surgery is recommended for serous BOT with micropapillary appearance and unsatisfactory abdominal cavity inspection during initial surgery (Grade C). Restaging surgery is recommended in case of mucinous BOT if only a cystectomy has been performed or the appendix has not been visualized, then a unilateral adnexectomy will be performed (Grade C). If a restaging surgery is decided in the management of a presumed early stage BOT, the actions to be carried out are as follows: a peritoneal cytology (Grade C), an omentectomy (there is no data in the literature recommending the type of omentectomy to be performed) (Grade B), a complete exploration of the abdominal cavity with peritoneal biopsies on suspect areas or systematically (Grade C), visualization of the appendix± the appendectomy in case of pathological macroscopic appearance (Grade C), unilateral adnexectomy in case of mucinous TFO (Grade C).

Tumeurs frontières de l’ovaire. Recommandations pour la pratique clinique du CNGOF – Diagnostic et prise en charge des récidives

To provide recommendations for the diagnosis and management of the recurrence of Borderline Ovarian Tumour (BOT). Literature review by consulting Pubmed, Medline and Cochrane databases. In the case of BOT, most of recurrences are a new BOT without invasive contingent (LE2). In the case of bilateral BOT, bilateral cystectomy is associated with a shorter recurrence time compared to unilateral oophorectomy and contralateral cystectomy (LE2). In recurrent serous BOT, cysts are usually fluid thin-walled with vegetation, corresponding in the IOTA classification to a solid unilocular cyst (LE2). A size of the cyst less than 20mm is not a sufficient to eliminate the diagnosis of recurrent serous BOT (LE2). Recurrence of mucinous BOT predominantly appears as multilocular or as solid multilocular cysts (LE4). In the case of ovarian preservation, recurrences are most often observed on the preserved ovary(s) (LE2). Non-invasive peritoneal recurrence after initial radical treatment including bilateral hysterectomy and adnexectomy is possible, mainly in patients initially diagnosed with stage II or III BOT with non-invasive peritoneal implant (LE3). Most BOT recurrences are asymptomatic, but clinical examination may allow diagnosis of recurrence (LE2). The normality of the CA 125 dosage does not rule out the diagnosis of recurrent BOT (LE2). A second conservative treatment in the event of recurrence of BOT entails the risk of new recurrence (LE2) with no impact on survival (LE4). Totalization of the adnexectomy in case of recurrence of BOT reduces the risk of new recurrence (LE2). Conservative treatment does not increase the risk of recurrence with non-invasive peritoneal implants (LE4). Conservative treatment may be offered after a first non-invasive recurrence in young women who wish to preserve their fertility (gradeC). In the absence of infiltrating tumor, chemotherapy is not indicated. The only cases for which chemotherapy can be considered are those for which there is an infiltrative component in addition to TFO.

Tumeurs frontières de l’ovaire. Recommandations pour la pratique clinique du CNGOF – Texte court

This work was carried out under the aegis of the CNGOF (Collège national des gynécologues et obstétriciens français) and proposes guidelines based on the evidence available in the literature. The objective was to define the diagnostic and surgical management strategy, the fertility preservation and surveillance strategy in Borderline Ovarian Tumor (BOT). No screening modality can be proposed in the general population. An expert pathological review is recommended in case of doubt concerning the borderline nature, the histological subtype, the invasive nature of the implant, for all micropapillary/cribriform serous BOT or in the presence of peritoneal implants, and for all mucinous or clear cell tumors (grade C). Macroscopic MRI analysis should be performed to differentiate the different subtypes of BOT: serous, seromucinous and mucinous (intestinal type) (grade C). If preoperative biomarkers are normal, follow up of biomarkers is not recommended (grade C). In cases of bilateral early serous BOT with a desire to preserve fertility and/or endocrine function, it is recommended to perform a bilateral cystectomy if possible (grade B). In case of early mucinous BOT, with a desire to preserve fertility and/or endocrine function, it is recommended to perform a unilateral adnexectomy (grade C). Secondary surgical staging is recommended in case of serous BOT with micropapillary appearance and uncomplete inspection of the abdominal cavity during initial surgery (grade C). For early-stage serous or mucinous BOT, it is not recommended to perform a systematic hysterectomy (grade C). Follow up after BOT must be pursued for more than 5 years (grade B). Conservative treatment involving at least the conservation of the uterus and a fragment of the ovary in a patient wishing to conceive may be proposed in advanced stages of BOT (grade C). A new surgical treatment that preserves fertility after a first non-invasive recurrence may be proposed in women of childbearing age (grade C). It is recommended to offer a specialized consultation for Reproductive Medicine when diagnosing BOT in a woman of childbearing age. Hormonal contraceptive use after serous or mucinous BOT is not contraindicated (grade C).

Comment je fais… Une résection de pastille diaphragmatique pour nodule de carcinose péritonéale par laparotomie sans mise en place de drain thoracique

Carcinome séreux de bas grade ovarien à un stade avancé : étude rétrospective sur 34 patientes en résection complète

Low-grade serous ovarian cancer is a distinct, slow-growing entity that affects mainly young women. The objective of this study was to describe the clinical characterisitics and survival outcomes of a population of patients suffering from advanced stage CSBG. A retrospective study was carried out in patients with advanced stage ovarian CSBG (FIGO IIIb-IV) who had complete macroscopic cytoreductive surgery, at Gustave Roussy Institut, Villejuif, between 2004 and 2017. Thirty-four patients were included, who were mainly young women (mean age 41.3 years), diagnosed at FIGO stage IIIC (91 %). The median follow-up was 41 months. Neoadjuvant chemotherapy was administered in 16 patients (47.1 %), and complete response never occurred. Upper abdominal surgical procedures were necessary in 90 % of cases and a bowel resection was performed in more than 80 % of cases. Over 90 % of patients received adjuvant chemotherapy followed by maintenance treatment with bevacizumab in over 40 % of cases. During follow-up, 9 (26 %) deaths occurred. Five-year overall survival was 70 % and disease-free survival was 20 %. CSBG of the ovary has a low chemosensitivity and requires maximum surgical management, which should be performed in expert centers.

Cancers épithéliaux de l’ovaire et chirurgie de cytoréduction par voie mini-invasive après chimiothérapie néoadjuvante : revue systématique de la littérature

Advanced epithelial ovarian cancer (EOC) is associated with high mortality and often managed first with neoadjuvant chemotherapy (NACT) followed by debulking surgery. Laparoscopic surgery with or without robotic assistance (Minimally Invasive Surgery (MIS)) may represent a beneficial option for these patients. The objective of this literature review is to clarify the place of MIS in the management of advanced EOC for selected patients. Pubmed, Cochrane and Clinicaltrials.gov online databases were used for this review, to select English or French published articles. We selected 11 original articles published between 2015 and 2020, 6 of which compared MIS and laparotomy. Among these 11 studies, 8 were retrospective cohorts, 2 were phase II trials, and one was a case-control study. In total, there were 3721 patients, of which 854 (23%) were treated with MIS. The robotic assistance was used with 224 patients (26%) of those MIS patients. Looking specifically at MIS patients, the laparoconversion rate was 9.5%, the rate of complete resection (CC-0) was 83.4%. Finally, the MIS complication rate was 1% intraoperatively and 12% postoperatively. The rate of complete resection, postoperative complication, as well as overall survival (OS) were comparable between patients treated with MIS or laparotomy. One study found an improved disease-free survival (DFS) in MIS versus laparotomy (18 months versus 12 months; P=0.027). MIS seems feasible, effective, and reliable in comparison to laparotomy for the completion of cytoreductive surgery after NACT without compromising oncological safety. Prospective randomized controlled trials are needed to confirm the role of MIS in advanced EOC.

La préservation de fertilité en cas de cancer du col, analyse de 30 ans de pratique et immersion dans les évolutions à venir

The strategy of fertility preservation (FP) in cervical cancer has been challenged for several years and a therapeutic de-escalation seems to be necessary. In this context, we evaluated the oncological, fertility and obstetric outcomes of surgical techniques performed in our centre for FP. This retrospective uni centric trial included 75 patients, managed at the Gustave Roussy Institute between 1995 and 2020, for cervical cancer (stage IB1 FIGO 2018) and having conducted a fertility preservation project after a complete pre-therapy work-up. The objective of this study was to understand our results on fertility and obstetrical outcomes and to correlate them with oncological data and finally to evaluate the evolution of our surgical practices. 54 patients benefited from an extended trachelectomy and no lymph node involvement was found. 1 patient received a complementary treatment postoperatively which did not allow to preserve her fertility. The recurrence rate was 4.8% (4/75) with one death described. 31 pregnancies were obtained, representing a pregnancy rate of 50%. 74% of pregnancies were obtained spontaneously and 60% of pregnancies were carried to term. Our results are similar to those in the literature. Despite a fertility preservation project, only half of the patients were able to achieve a pregnancy.

Stadification ganglionnaire lombo-aortique dans les cancers du col de stade supérieur ou égal à IB2: comparaison des performances du PETscan au 18FDG et du curage lombo-aortique à partir des données du registre des cancers gynécologiques de Côte d’Or de 2003 à 2016

Current guidelines (ASCO, ESTRO, and ESGO) recommend para-aortic lymphadenectomy (PAL) for lymph node staging in patients with a negative initial PET-CT in locally advanced cervical cancer (LACC), with the aim to determine the radiation fields for radiochemotherapy. The main goal of this study was to compare overall survival (OS) in two groups, which differed according to the para-aortic lymph node staging technique used: imaging alone versus imaging and PAL. Secondary objectives were to determine recurrence-free survival (RFS), the proportion of false negatives on PET-CT, and surgery-related complications. We conducted a retrospective, observational study on data from the Côte d'Or gynaecological cancer registry collected from 2003 to 2016, and compared two groups of LACC with different techniques for staging para-aortic lymph nodes: PET-CT alone (iN group) (n=99) and PET-CT associated with PAL (pN group) (n=35) for a total of 134 patients. OS (HR=1.04 (95% CI: 0.53-2.03); P=0.9) and RFS (HR=0.65 (95% CI: 0.29-1.45); P=0.29) were similar in both groups. There were 11.4% of false negatives in PET-CT, and 2.9% of patients who underwent PAL experienced complications. The staging method, iN or pN, had no impact on the time to the implementation of concomitant radiochemotherapy. For lymph node staging in LACC, PAL after a PET-CT as compared with PET-CT staging alone, had no significant impact on OS or RFS.

Élaboration d’une base de recueil nationale prospective des données cliniques sur le cancer du col utérin: utilisation de la méthode Delphi pour l’identification de variables consensuelles

Cervical cancer (CC) is associated with poor prognosis and therapeutic morbidity in young women. The impact of European recommendations for treatments and follow-up of these patients must be assessed. There is no real-time CCU tracking basis. Main objective of our study was to identify the items of the clinical and therapeutic data necessary for the constitution of a national, dynamic and prospective clinical database allowing to characterize treatments and follow-up of patients with CC in France. An exhaustive bibliographic research was lead with the help of the ESGO recommendations. A list of qualitative and quantitative variables characterizing CC was established. These variables were assessed by a panel of national experts from the Francogyn group, using the Delphi survey. The rate of agreement was calculated for each variable. 345 variables divided into 6 sections were identified and submitted to 26 experts. 17 experts responded to the three rounds of the Delphi method. A total of 273 items were validated. The majority of experts (90 %) also gave a favorable opinion on the addition of a quality of life section in the database. This is the first study identifying 273 items chosen by consensus. The items are collected in a future national gynecological database "Epigyn".

Applicabilité de l’Adnex score dans la prédiction de la malignité des kystes ovariens

Ovarian cancer screening is a difficult problem due to the anatomy of the ovaries. Only histology allows a definite diagnosis. Our objective was to study the contribution of the Adnex score in the histological characterization of adnexal images for adequate management. It was a retrospective, mono-center, descriptive and analytical. Sixty-five patients were included, those operated for an ovarian cyst and meeting the Adnex criteria: clinical, ultrasound and laboratory. The mean age of the patients was 38.6 years. They were nulliparous in 43 % of cases, and only four had a history of operation on ovarian cyst. Abdominal pelvic pain was the most frequent reason for consultation in 48 % of cases. An abdominopelvic mass was found on abdominal examination in 11 % of cases. Pelvic ultrasound made it possible to objectify the presence of an ovarian mass in all cases, with an average size of 79.66mm and a reassuring appearance in 66 % of cases. The calculation of the Adnex score was done in all patients preoperatively, for a 10 % cut-off, the model showed an 86 % chance of benignity for tumors proven to be histologically benign. The main route of entry was laparoscopy, in 61 % of cases. The treatment was in most cases conservative consisting essentially of a cystectomy. The Adnex score discriminated well between benign and malignant masses, allowing for a better diagnosis preoperatively. It thus deserves its applicability in the clinical setting.

Comment je fais… une myolyse par radiofréquence de myomes utérins par voie cœlioscopique ? (avec vidéo)

Le groupe FRANCOGYN : bilan et avenir

Describing the constitution of the FRANCOGYN group (a national French research group in Oncological and Gynecological Surgery) and present its current and future development. Literature review using PUBMed database with the keyword "FRANCOGYN". Describing the constitution of the FRANCOGYN group (a national French research group in Oncological and Gynecological Surgery) and present its current and future development. The FRANCOGYN group was formed in December 2015, bringing together over the years more than 17 gynecological and oncological surgical department in France. The group carries out clinical research on gynecological pelvic cancers by constituting retrospective cohorts. Its legitimacy allows it to lead or co-lead the drafting of recommendations for clinical practice in the field of gynecological cancers. It now offers prospective randomized research funded by national grants. The FRANCOGYN network allows us to propose a national reflection on the surgical management of pelvic cancers in women, resulting in numerous international reference publications.

Devenir des femmes de moins de 30 ans prises en charge pour une lésion intra-épithéliale de haut grade du col utérin non traitée

To assess the probability of spontaneous regression of high grade cervical intraepithelial neoplasia (HGCIN) in women under 30 and the predictive factors for such evolution. We conducted a bicentric retrospective study. A total of 98 patients under 30 and with untreated HGCIN were included from 01/01/2010 to 31/12/2019. For each patient, the initial clinical and colposcopic characteristics were systematically documented. In compliance with French guidelines, these patients were offered repeated 6-months colposcopic follow-up for 2years. The endpoint was the occurrence of spontaneous regression of the HGCIN defined by normalization of colposcopy, and/or a negative biopsy and/or a negative HPV test or histological regression to low grade CIN, or a colposcopy showing simple minor abnormalities requiring no biopsy. Spontaneous HGCIN regression was observed in 37/98 patients. The median follow-up was of 16 (10.5-24.3) months. Predictive factors for spontaneous regression were: minor initial cytological abnormalities (HR=3.4; 95% CI: 1.02-11.05) and grade 1 atypical transformation at initial colposcopy (TAG1) (HR=2.3; 95% CI: 1.1-4.7). Before 30, the probability of spontaneous regression of HGCIN exists but remains low. Predictive factors for such evolution are minor initial cytological abnormalities and TAG1 colposcopic impression.

Les actualités en génétique oncologique mammaire pour la population féminine et masculine

Le cancer du col de l’utérus : recommandations pour la pratique clinique

To establish clinical practice guidelines for the management of women with cervical cancer. An organizing committee composed of a chair, two coordinators, and a methodologist defined the questions to be addressed and appointed a working group of 36 experts. Questions were formulated using the PICO format (Patients, Intervention, Comparison, Outcome). A literature review was conducted using the GRADE® methodology, leading to the development of 130 questions. All texts and recommendations were based on the 2018 FIGO classification for cervical cancer. The recommendations were externally validated using the Delphi method with input from 87 experts. The 130 questions resulted in 158 recommendations covering the full spectrum of cervical cancer management: initial assessment (clinical, imaging, conization, nodal staging), treatment (surgery, chemoradiotherapy, brachytherapy, adjuvant therapies), response evaluation, follow-up, fertility preservation, management of recurrences, and three specific situations (incidental finding on hysterectomy specimen, residual cervix, and elderly women). Among the 158 recommendations, 35 were strong (including 5 based on very low-quality evidence), 52 were weak, and for 71, no recommendation could be made due to insufficient data. The quality of evidence was rated as high (n=20), moderate (n=15), low (n=25), or very low (n=27). These guidelines help harmonize the management of cervical cancer in France and support healthcare professionals with evidence-based decision-making tools.

Optimisation du dépistage du cancer du col de l’utérus en France : une étude clinique prospective multicentrique

In France, the rate of cervical cancer screening (CCS) coverage is estimated to be 53.4% in 2022 with a target of 80%. This study assessed the effectiveness of a strategy involving telephone reminders by general practitioners (GPs) to increase participation. This prospective, descriptive multicenter study was conducted in France in 2023. Eight hundred and thirty-one women aged between 25 and 65 years did not undergo up-to-date screening according to French recommendations and were contacted by a healthcare professional in the medical practices where they were followed up to schedule a screening appointment. The rate of patient participation in CCS for each GP was recorded before and after the inclusion period using the website (www.amelipro.fr). This study was approved by the French Data Protection Authority (Commission Nationale de l'Informatique et des Libertés) under No. 2227553 v. 0. The rate of participation in CCS increased from 53.4 to 63.8% following telephone calls of eligible patients who were not up-to-date with their screening. After receiving a telephone call, patients over 50 years of age had an acceptance rate similar to that of patients under 50 years of age despite their lower screening coverage. This study highlights the importance of personalized medicine for reducing inequalities. This measure is complementary to preexisting measures, such as organized screening, or planned measures, such as vaginal self-sampling.

Conduite à tenir devant une femme ayant une cytologie cervico-utérine anormale : actualisation des recommandations INCa après la mise en place du dépistage par le test HPV

To update the recommendations issued by the National Cancer Institute (INCa) on the management of women with abnormal cervical cytology. INCa recommendations on the management of women with abnormal cervical cytology were published in 2016. In 2019, the High Authority of Health (HAS) recommends HPV test for cervical cancer screening in women over 30. It was therefore necessary to update the initial management and follow-up of women with a reflex cytology abnormality after a positive HPV test. We used the modified Delphi method. Each decision tree was modified by the 3 members of the organizing committee and then presented to 35 experts over 2 rounds, in order to obtain their agreement in terms of validity and clarity. This formalized consensus of experts allowed the creation of 17 decision trees instead of 15 previously: 13 on the diagnostic management of abnormal cytology, stratified according to age, and 4 on therapeutic indications in abnormal histology. The median agreement scores were 89% (81-97). These 17 decision trees respond to the different situations that health professionals may encounter in order to enable them to act, to follow-up or delegate according to their specialties.

Caractéristiques épidémiologiques et histopathologiques de 1280 cancers du col utérin à Kinshasa

Due to the lack of both cancer registry and large scale cervical screening in most african countries, only theoretical studies are available. The objective of our work was to provide epidemiological and histopathological characteristics of cervical cancer based on concrete observations. This study was carried out on all cancers (n=5801) collected in the last 10 years from 5 pathology laboratories of Kinshasa; the histologic slides of the cervical cancers (n=1280) were reviewed by at least two pathologists and classified according to the 2014 OMS classification. The cervical cancers accounted for 22% of all cancers and 40,4% of breast and gynecological cancers. The cervical cancer was the most common among women aged 49-58. Squamous cell carcinomas were the most observed type (73,2%) followed by adenocarcinomas (18,4%) and adenosquamous carcinomas (8,4%). Keratinized (47,2%) and non keratinized squamous carcinoma (20,8%) were the most frequent subtypes among squamous carcinomas and the usual adenocarcinoma among adenocarcinomas (9,6%). In the mucinous adenocarcinoma subtype, only the signet ring cells (1,3%) variant was found. Among cervical cancers, 69% were grade I, 20% grade II and 11% grade III. Our study provides a concrete database of epidemiological and histopathological cervical cancer particularities in Kinshasa, useful to initiate a cancer register, as well as cervical screening and HPV vaccine campaigns.

Myolyse des fibromes utérins par radiofréquence cœlioscopique sous contrôle échographique : à propos d’une série rétrospective

To assess clinical and radiological efficacy and safety of laparoscopic ultrasound-guided radiofrequency ablation of uterine leiomyomas. Thirty-three patients with symptomatic uterine leiomyomas FIGO type 2 to 7, have undergone a laparoscopic ultrasound-guided radiofrequency ablation at Croix Rousse University Hospital Center (Hospices civils de Lyon) and at Saint-Vincent de Paul Hospital in Lille, between June 2020 and December 2022. The characteristics of each myoma and the symptoms were assessed with pelvic MRI and with Higham score, SSS and HRQL scores preoperatively and at 6 months. A total of 54 fibroids have been treated in 33 patients. We observed a significant decrease of the volume 6 months after the surgery, on average 21mL (55.97 vs. 74.37mL, 95% CI [7.13-34.88], P=0.001). The maximum diameter of each fibroid was also significantly reduced on average 11.78mm (41.89 vs. 52.06, 95% CI [8.83-14.73], P<0.05). We noticed a significant decrease of the NRS for dysmenorrhea on average 2.79 points (2.1 vs. 4.89, 95% CI [1.14-4.42], P<0.05). There was also a trend to improvement of menorrhagia, assess by Higham score. Indeed, 70.8% of the patients had menorrhagia. Menorrhagia was improved of 108,3 points with an average Higham score before surgery of 197.3 versus 87.9 after surgery (95% CI [47.9-168.8], P=0.001). Concerning UFS-QOL score: the symptom severity score (SSS) decreased on average 33 points, testifying of symptom improvement (27.04 vs. 60.89, 95% CI [22.92-43.39], P<0.001) and the HRQL score increased on average 20 points testifying quality of life improvement (65.57 vs. 42.7, 95% CI [15.83-37.85]. P<0.001). No severe adverse event has been reported. In this first French study about radiofrequency ablation. We confirm its efficiency for improvement of symptoms and quality of life but other study is mandatory to confirm the safety of this procedure in particular in patients with a wish to conceive.

Facteurs de risque de lésions malpighiennes intra-épithéliale de haut grade ou de cancer du col de l’utérus en cas de maladie inflammatoire chronique de l’intestin

Chronic inflammatory bowel disease (IBD) is thought to increase the risk of high-grade histological intraepithelial lesions (HGIL) and cervical cancer. The risk factors for developing these lesions are poorly understood. This is a single-center retrospective case-control study including IBD patients followed at our University Hospital Center from 2011 to 2021 who presented with HGIL or cervical cancer. Four controls were case-matched according to IBD type, age, active smoking and multiparity. Eighteen cases and 72 controls were included. We found no significant differences between the 2 groups with regard to mean age at IBD diagnosis, mean duration of IBD, IBD location, history of IBD-related surgery or even association with another chronic inflammatory disease. In our study, the use of immunosuppressants/biotherapies in these patients [50% (9/18) for cases vs. 56% (40/72) for controls; P=0.9] was not a risk factor for IGRA or cervical cancer. Similarly, neither the total duration of exposure to immunosuppressants/biotherapies (9.9±8years for cases vs. 6.6±5.3years for controls; P=0.1), nor combined therapies [11% (2/18) for cases vs. 6% (4/72) for controls; P=0.3], nor azathioprine or methotrexate use [22% (4/18) for cases vs. 11% (8/72) for controls; P=0.3] were found to be risk factors. In our study, we found no risk factors for patients with IBD to develop IGRA or cervical cancer.

Encéphalite auto-immune à anticorps anti-récepteur NMDA et tératome ovarien

Incidence et impact de la maladie thrombo-embolique sur la prise en charge du cancer de l’ovaire

Ovarian cancer is a risk factor for venous thromboembolism (VTE), which worsens overall survival. The main objective of our study was to calculate the incidence of VTE in our population. We analyzed VTE impact on diagnosis and management of ovarian cancer. We conducted a retrospective, monocentric study in ovarian, fallopian tube and primary peritoneal cancer patients, divided into 2 groups (« Presence of VTE » and « Absence of VTE »). A univariate and multivariate analysis of factors associated with VTE was performed, and we compared delays of management in both groups. Among 157 patients included in the study, 22.9% presented a VTE, and 52.8% were asymptomatic. The VTE was diagnosed prior to any treatment in 61.1% of patients and revealed the ovarian cancer in 27.8% of cases. In multivariate analysis, tumor size (OR=1.1, 95% CI: 1-2.21, P=0.012), malnutrition (OR=3.79, 95% CI: 1.16-12,4, P=0.028) and Ddimer level above 1.5μg/mL (OR=13.8, 95% CI 1.2-152.8, P=0.02) were significantly associated with VTE. No significant difference was found between the two groups in diagnostic or therapeutic strategy, as well as in delays of management. We report a high incidence of VTE in ovarian cancer, including a lot of asymptomatic events. An early diagnosis with clinical examination and Ddimer level could improve its management and its prognosis.

Tumeurs frontières de l’ovaire. Recommandations pour la pratique clinique du CNGOF – Imagerie

To determine the place of imaging and the performance of different imaging techniques (transvaginal ultrasound with or without Doppler, scoring, CT, MRI) to differentiate benign tumour, borderline ovarian tumour (BOT) and malignant ovarian tumor. Differentiate the histological subtypes of BOT (serous, sero-mucinous, mucinous) and prediction in imaging of the possibility of conservative treatment. The research was carried out over the last 16 years using the terms "MeSH" based on the query of the Medline® database and supplemented by the review of references contained in the meta-analyzes, systematic reviews and original articles included. Endo-vaginal and suprapubic ultrasonography is recommended for analysis of an ovarian mass (grade A). In the case of ultrasound by a referent, subjective analysis is the recommended technique (grade A). In case of echography by a non-referent, the use of "Simple Rules" is recommended (grade A) and should be best combined with subjective analysis to rejoin the performance of a sonographer refer (grade A). In cases of undetermined ovarian lesions in endovaginal ultrasound and suprapubic ultrasound, it is recommended to perform a pelvic MRI (grade A). The MRI protocol should include T2, T1, T1 sequences with fat saturation, diffusion, injected dynamics, and after gadolinium injection (grade B). To characterize an MRI-adnexal image, it is recommended to include a risk score for malignancy (ADNEX-MR/O-RADS) (grade C) in the report and to formulate an anatomopathological hypothesis (Grade C). The predictive signs of benignity in front of a cyst with endocystic vegetations are the low number, the small size, the presence of calcifications and the absence of Doppler flow in case of size greater than 10mm in echography (LP 4) and a curve of type 1 MRI (LP4). MRI is recommended for suspicious lesions of BOT in ultrasound (grade B) or indeterminate lesions in ultrasound (grade A). There is no data to support the usefulness of CT or PET-CT for BOT. Morphological criteria in ultrasound and MRI exist to differentiate BOT from invasive tumors regardless of grade (NP 2). Pelvic MRI is recommended to characterize a tumor suggestive of ultrasound BOT (grade C). No recommendations can be made about the use of combined ultrasound, biological, and menopausal status scores for the diagnosis of BOT. The diagnostic performance of imaging to detect peritoneal implants of BOT is not known. The assessment of the invasiveness of peritoneal implants of imaging BOT has not been evaluated. The association of macroscopic signs in MRI makes it possible to differentiate the different subtypes - serous, sero-mucinous and mucinous (intestinal type) - of BOT, despite the overlap of certain presentations (LP3). The analysis of macroscopic MRI signs must be performed to differentiate the different subtypes of TFO (grade C). No recommendation can be made on imaging prediction of the possibility of conservative BOT treatment.

Comment je fais… une omentosplénectomie par laparotomie au cours d’une chirurgie de réduction tumorale complète ?

Comment je fais… un curage inguinal dans les cancers vulvaires

Comment je fais… pour m’exposer simplement sans manipulateur et limiter le risque de dissémination tumorale lors d’une hystérectomie pour cancer ?

Technique chirurgicale du curage inguinal superficiel et profond dans le cancer de la vulve, avec vidéo

Lésions vulvaires précancéreuses : mise au point

Vulvar carcinomas represent 4% of all gynaecological cancers with 838 new cases in France in 2018. The precursor lesions of vulvar carcinomas are differentiated vulvar intraepithelial lesion (dVIN) in a context of lichen sclerosus and vulvar high-grade squamous intraepithelial lesion (HSIL) link to human papillomavirus (HPV) infection. Three typical clinical forms of HSIL are described: the Bowenoid papulosis, the Bowen's disease and the confluent VIN. Histopathology cannot differentiate effectively these two types of lesions. P16 and P53 immunostaining are valuable tools to respectively assess HPV infection and divide different types of dVIN. However, P53 immunostaining is still lacking sensibility to detect dVIN. First line therapies are medical treatment excluding the cases with a doubt of invasion. The gold standard treatment for dVIN and vulvar HSIL are respectively topical corticosteroids and imiquimod. Primary prevention for vulvar HSIL and dVIN are respectively HPV vaccination and early treatment of lichen sclerosus. Destructive therapy can be used in case of medical treatment failure such as CO2 laser, cryotherapy, dynamic phototherapy. Surgical indications should be carefully assessed between the risk of recurrence, the spread of the lesions, the aesthetic and functional aspect. Surgical procedures consist in either superficial vulvectomy or radical vulvectomy with or without flap reconstruction. Recurrence rate after surgery is around 20%.

Prise en charge des lésions cervicales HPV induites chez les patientes immunodéprimées – Revue de la littérature

Current French recommendations for the management of cervical lesions related to human papilloma virus (HPV) infection are limited to general population. Patients who are immunocompromised appear to be at increased risk of induced HPV lesions. The objective of this review is to summarize the various existing data about risk of induced HPV lesions in immunocompromised patients to specify the management. The Medline database was searched through the Pubmed portal, as well as the recommendations of various international learned societies. Situations with an increased risk are regardless of treatment: Human Immunodeficiency Virus (HIV) infection, transplants, lupus. Patients with chronic inflammatory bowel disease (IBD) and rheumatoid arthritis are at increased risk only when immunosuppressive therapy is required. Screening for dysplasic intraepithelial lesions in HIV+ patients should be more sustained than in the general population. Due to lack of data, recommendations for other conditions have been extrapolated from the management of HIV+ patients. HPV vaccination is effective in these populations, particularly at times when the immune system is the most effective. Identified immunocompromised populations are at higher risk of induced HPV lesions due to an incomplete immune response and should be screened on a sustained basis. In addition, HPV vaccination should be encouraged.

Performances de l’IRM dans le bilan d’extension locale préopératoire des cancers de l’endomètre : l’expérience nantaise

To determine the diagnostic accuracy of magnetic resonance imaging (MRI) for local preoperative staging in endometrial cancer in our center (Centre Hospitalier Universitaire de Nantes: CHU), since the French National Cancer Institute's surgery recommendations publication in 2010, especially for the prediction of myometrial and cervical stromal invasion. Retrospective monocentric study of consecutive women operated of endometrial cancer in gynecology department of CHU de Nantes, who underwent preoperative pelvic MRI in our Radiology department from November 2010 to November 2016. MRI data collected from initial report and compared to surgical histological findings as gold standard. Sixty-four patients were included. Deep myometrial invasion was present in 35 patients in MRI versus 34 patients on postoperative histology (5 false positives, 4 false negatives). Cervical stromal invasion was present in 9 patients in MRI versus 19 patients on postoperative histology (2 false positives, 12 false negatives). The sensitivity and the specificity were respectively 88.23% (95% confidence intervals (CI) [0.71-0.96]) and 83.33% (CI [0.64-0.93]) for the deep myometrial invasion; 36.84% (CI [0.17-0.61]) and 95.55% (CI [0.83-0.99]) for the cervical stromal invasion. Our results were comparable to the literature data, with a low sensitivity for the cervical stromal invasion detection, driving us to change our MRI protocol with optional high-resolution T2 sequences perpendicular to the cervical canal if necessary.

Probabilité diagnostique d’une lésion de haut grade chez les patientes ASCUS HPV positif en fonction du typage HPV

The aim of our study was to assess the proportion of high-grade histological lesions, according to HPV type, in patients referred for colposcopy involving a positive HPV-HR test and ASC-US cytology. This is a retrospective descriptive study of asymptomatic patients aged 25 to 65 with a positive HPV-HR test and ASC-US cytology. Data were collected at the Nord Franche-Comté Hospital from September 2019 to February 2022. The primary outcome was the proportion of high-grade histological lesions in patients with ASC-US cytology combined to HPV 16 or 18 (associated or not with other HPV type), compared with HPV no 16 no 18. Among the 298 patients included, 67% were HPV no 16 no 18, 22% HPV 16 associated or not with others and 11% HPV 18 associated or not with others. We found significantly fewer high-grade lesions in patients with ASC-US cytology and HPV no 16 no 18 than in patients with HPV 16 or 18 (8.5% versus 22.7%, P<0.01). In patients presenting an ASC-US cytology with HPV no 16, no 18: 53% of the biopsies found no histological lesion compared with 30% for the other HPVs (P<0.01). We have highlighted the reality of colposcopists: a high ratio of normal coloscopy associated with normal or low-grade biopsies, in patients with a positive HPV-HR test no 16, no 18 and ASC-US cytology.

Curage lombo-aortique et cancers gynécologiques pelviens : cœlioscopie rétroperitonéale ou transpéritonéale ?

Para-aortic lymphadenectomy plays a fundamental role in the surgical management of pelvic gynecological cancers. Two laparoscopic approaches exist: the transperitoneal (TP) and the extraperitoneal (EP). The aim of this study was to compare these 2 approaches in terms of surgical outcomes, specially the number of removed lymph nodes according to the surgical technique, and morbidity. A single-center retrospective study was carried out at the Lariboisiere University Hospital between January 2011 and March 2020 including all patients who underwent para-aortic lymphadenectomy for the management of a pelvic gynecological cancer (cervix, endometrium, ovary). Univariate and multivariate analysis (logistic regression) were performed to compare the TP and the EP groups. 143 patients were included: 74 in the TP group and 69 in the RP group. The total duration of surgery was 220.8minutes in the TP group and 166.4minutes in the EP group (P<0.001 in multivariate analysis). No significant difference between groups were found in the average total number of lymph nodes removed but there was a statistically significant difference in the average latero-aortic number of lymph nodes removed: 8.5 lymph nodes in the TP group and 11.3 lymph nodes in the group RP (P<0.001 in multivariate analysis). There was no difference between groups in peri and postoperative morbidity. EP para-aortic lymphadenectomy reduces duration of surgery and increases the average latero-aortic number of lymph nodes removed with same morbidity compared to TP para-aortic lymphadenectomy, this confirming its preferred indication in endometrial and in cervical cancers.

Quelles nouveautés pour la prise en charge du cancer de l’endomètre ? Le point sur les recommandations européennes de 2021

The new European guidelines for the management of patients with endometrial cancer were published in early 2021. These recommendations are joint to the three European Learned Societies of Gynecologic Oncology (ESGO), Radiation Therapy and Oncology (ESTRO) and Anatomical Pathology (ESP). On behalf of the French Society of Gynecologic Oncology (SFOG), we wish to bring to the knowledge of the French-speaking readership the main measures for the management of patients which represent an advance compared to the 2016 recommendations. The new European recommendations for the management of patients with endometrial cancer emphasize the generalization of micro-satellite instability (MSI) or immunohistochemical analysis of MMR system proteins for all patients. Also, the classification into 4 prognostic risk groups integrates data from molecular analysis (p53, MSI, POLE) to guide initial surgical management as well as adjuvant treatment modalities. The indocyanine green sentinel node procedure has also become the reference technique for FIGO I and II lymph node staging regardless of histological type. It should be remembered that management should be provided in a specialized institution by a team specialized in the management of gynecological cancers, particularly for high-risk and/or advanced cancer patients.