utérin [661]. Les schémas de traitement comportaient une radiothérapie pelvienne suivie d'une curiethérapie à haut débit de dose. Les survies sans récidives et spécifiques au cancer ne montraient pas de différence significative dans les 2 groupes d'âge à stade égal de la maladie. Douze sur 79 (15,0 %) patientes de plus de 70 ans et 14/179 (7,8 %) des patientes de moins de 70 ans ont développé des complications rectales de grade 3-4 (p = 0,12), et 7/79 (8,9 %) de plus de 70 ans et 10/179 (5,6 %) de moins de 70 ans ont développé des complications de l'intestin grêle de grade 3-4 (p = 0,34) [661].

**Synthèse** : la curiethérapie augmente la survie des patientes âgées de plus de 70 ans atteintes d'un cancer du col avancé par rapport à l'absence de curiethérapie avec un contrôle de la maladie tumorale similaire aux patientes plus jeunes. La curiethérapie est moins réalisée chez les patientes de plus de 70 ans du fait de raisons techniques (absence d'accouchement par les voies naturelles ou liée à la taille tumorale) pour 48,7 % des cas, des comorbidités de la patiente pour 69,4 % des cas et refus de la patiente dans 38,3 % des cas.

**10.3.4. Question 128 :** Chez une patiente âgée (i.e., de plus de 70 ans ou 75 ans) atteinte d'un cancer du col de stade avancé (P), le curage ganglionnaire lombo-aortique de stadification (I) versus l'absence de curage (c) permet-il d'améliorer le pronostic (ou la survie) (O) ? (PICO 128)

## Recommandation 128

Chez une patiente âgée (i.e., de plus de 70 ans ou 75 ans) atteinte d'un cancer du col de stade avancé, les données actuelles de la littérature ne permettent pas d'émettre de recommandation sur la pratique du curage ganglionnaire lombo-aortique de stadification versus l'absence de curage afin d'améliorer le pronostic ou la survie. Pour ces patientes, la décision de la réalisation d'un curage ganglionnaire lombo-aortique doit être prise au cas par cas en s'appuyant sur la balance bénéfice-risque.

# ABSENCE DE RECOMMANDATION

## Introduction

Il existe environ 2800 nouveaux cas de cancer du col de l'utérus par an avec un peu moins de 900 décès par an en France, pays où un dépistage est organisé jusqu'à 65 ans. Le premier pic d'incidence du cancer du col de l'utérus est aux environs de 45 ans, mais il existe un second pic d'incidence entre 60 et 70 ans [636]. Environ 30 % des cancers du col utérin sont diagnostiqués après 65 ans avec 53 % des décès dus à cette pathologie [637-639]. La survie spécifique liée au cancer à 5 ans est de 38 % pour la population de plus de 75 ans contre 66 % (65-75 ans) à 82 % (15-44 ans) pour toutes les autres tranches d'âge (Invs 2008). Les données des autres pays occidentaux sont proches, par exemple la base de données américaine SEER montre que 21 % des cancers du col utérin sont diagnostiqués après 65 ans [640].

Les personnes âgées de plus de 65 ans atteintes d'un cancer du col utérin sont diagnostiquées à un stade plus avancé que les personnes plus jeunes : 54,8 % à un stade FIGO IB2-IVA et 33 % à un stade FIGO IVB pour les personnes de plus de 65 ans contre 33,7 % et 8,0 % pour les moins de 45 ans en France [639]. Sur la base américaine SEER, on retrouve des chiffres à 42 % et 22 % respectivement pour les plus de 65 ans et 34 % et 13 % pour les moins de 65 ans, respectivement [640].

Pour les patientes atteintes d'un cancer du col utérin localement avancé (stade IB2-IVA de la FIGO), seulement 29,2 % des patientes de plus de 65 ans reçoivent le traitement recommandé (i.e., radio-chimiothérapie concomitante et curiethérapie) contre 51,9 % à 66,1 % pour les différentes tranches d'âge de moins de 65 ans en France [639]. En miroir pour les stades précoces (traitement recommandé : chirurgie) et les stades métastatiques (FIGO IVB) (traitement

recommandé : chimiothérapie), les pourcentages du respect des recommandations sont plus concordants entre les tranches d'âge [639].

Pour les cancers du col localement avancés, le traitement recommandé est la radio-chimiothérapie concomitante suivie d'une curiethérapie. En option, il est possible de réaliser une lymphadénectomie pré-thérapeutique (pré-RCC) lombo-aortique ± pelvienne pour évaluer l'envahissement ganglionnaire notamment lombo-aortique afin de guider les champs d'irradiation. L'objet de la présente PICO est de déterminer si la lymphadénectomie lombo-aortique ± pelvienne apporte un bénéfice dans la population des personnes âgées atteintes d'un cancer du col de l'utérus localement avancé par rapport à l'absence de lymphadénectomie.

Le curage lombo-aortique ± pelvien pour la stadification préthérapeutique d'un cancer du col localement avancé ne se conçoit que par voie mini-invasive (cœlioscopie classique ou robot-assistée), le plus souvent par voie rétropéritonéale (plutôt que transpéritonéale) [185]. La réalisation d'une lymphadénectomie lombo-aortique a une certaine morbidité et est potentiellement encore plus morbide chez les personnes âgées. Les personnes âgées ont des comorbidités cardio-vasculaires et respiratoires pouvant compromettre le maintien du Trendelenburg nécessaire à la réalisation du geste technique [663]. Par ailleurs, la présence d'une athérosclérose, plus fréquente chez les personnes âgées, peut augmenter les complications d'un curage. L'alternative possible au curage pour la stadification ganglionnaire peut être la réalisation d'une TEP-TDM dont un risque de faux négatif est de 9 % en l'absence d'hypermétabolisme ganglionnaire pelvien et de 22 % en cas d'hypermétabolisme ganglionnaire pelvien [185].

## Argumentaire

Il n'existe pas d'étude randomisée réalisée dans une population de personnes âgées atteintes d'un cancer du col de l'utérus localement avancé comparant le curage lombo-aortique versus l'absence de curage lombo-aortique. Ici une seule étude rétrospective de faible effectif a permis d'appréhender la question PICO. Seule une étude prospective, randomisée, multicentrique pourrait permettre de répondre à la question de manière plus robuste.

Dans la littérature, nous avons retrouvé une seule étude qui traite de la place de la lymphadénectomie préthérapeutique dans le cancer du col chez les personnes âgées et donc en lien avec la question PICO. Il s'agit d'une étude rétrospective polonaise unicentrique publiée par Koper K. et al. [664]. Dans cette étude, 75 femmes ont été incluses entre 2008 et 2013. Elles avaient un diagnostic de cancer du col utérin localement avancé (supérieur ou égal à IB2 de la FIGO) et ont toutes bénéficié d'une RCC puis d'une curiethérapie. La lymphadénectomie était réalisée avant la RCC. La lymphadénectomie était pelvienne uniquement pour 21 patientes et pelvienne et lombo-aortique pour 54 patientes. En cas de lymphadénectomie lombo-aortique, elle était réalisée uniquement jusqu'au niveau de la mésenterique inférieure. Dans cette série, 22 patientes avaient plus de 62 ans et donc 53 patientes de moins de 62 ans. La réalisation d'un curage lombo-aortique et pelvien améliorait la survie de manière indépendante à 5 ans par rapport à un curage pelvien seul (aOR 0,52 [0,28-0,98] p = 0,04) dans l'ensemble de la cohorte. Les patientes de plus de 62 ans avaient une survie globale significativement plus faible que les patientes plus jeunes. Dans cette étude, il n'a pas été montré d'analyse de survie par sous-groupe d'âge (moins et plus de 62 ans) en fonction du type de lymphadénectomie réalisée. Dans cette étude il n'est pas rapporté non plus la morbidité du curage préthérapeutique. De même, il n'existe aucune donnée sur une éventuelle évaluation onco-gériatrique préalable.

Cette étude est donc une étude de qualité de preuve très faible, évaluant la place de la lymphadénectomie chez une cohorte très faible de patientes âgées atteintes d'un cancer du col localement avancé (22 patientes de plus de 62 ans), sans bras de comparaison dans une population de femmes âgées sans lymphadénectomie. Cette étude montre simplement que la lymphadénectomie est faisable dans cette
population sans apporter de preuve de son bénéfice dans ce sous-
groupe de patientes âgées.

Dans une autre étude, Gallotta et al. ont évalué la faisabilité du
curage lombo-aortique par voie robotique dans les cancers gynéco-
logiques chez les patientes âgées de plus de 65 ans [665]. Dans cette
étude, il y avait 25 patientes atteintes d'un cancer du col utérin (23 de
65 à 75 ans et 2 de plus de 75 ans). Cette étude montre la faisabilité du
curage lombo-aortique par voie coelioscopique robot-assistée pour
16 patientes de 65 à 75 ans et 4 de plus de 75 ans sans différence
significative en termes de complications périopératoires.

Dans une revue de la littérature ciblant les patientes âgées atteintes d'un cancer du col de l'utérus, Kissel et al. indiquaient en 2020 que l'indication de lymphadénectomie lombo-aortique chez les personnes âgées atteintes d'un cancer de l'ovaire est une indication au cas par cas à prendre dans un contexte de staff multidisciplinaire [666].

Synthèse : la place de la lymphadénectomie lombo-aortique ± pelvienne est déjà controversée chez les patientes jeunes (moins de 65 ans) atteintes d'un cancer du col de l'utérus localement avancé [199], avec des données contradictoires sur les bénéfices en survie, (même en utilisant un algorithme s'appuyant sur la TEP-TDM) [161]. Les données publiées sur le bénéfice de la lymphadénectomie lombo-aortique ± pelvienne chez les personnes âgées atteintes d'un cancer du col de l'utérus localement avancé sont quasiment inexistantes. En l'absence de données de la littérature, il n'y a pas d'argument pour proposer préférentiellement une lymphadénectomie lombo-aortique ou non pour la prise en charge d'une patiente âgée (plus de 65 ans) atteinte d'un cancer du col de l'utérus localement avancé. Il existe une plus forte morbidité en cas de réalisation d'une lymphadénectomie lombo-aortique préthérapeutique qu'en l'absence de celle-ci. Il n'est pas possible d'établir quel est le souhait des patientes entre ces deux stratégies.

10.3.5. Question 129 : Chez une patiente âgée (i.e., de plus de 70 ans ou 75 ans) atteinte d'un cancer du col de l'utérus (P), une évaluation gériatrique préthérapeutique (I) versus l'absence d'évaluation gériatrique (c) permet-elle d'améliorer le pronostic (ou la survie) (O) ? (PICO 129)

Recommandation 129

Chez une patiente âgée (i.e., plus de 70 ans) atteinte d'un
cancer du col utérin, les données actuelles de la littérature ne
permettent pas de conclure dans le contexte spécifique du
cancer du col à l'intérêt d'une évaluation gériatrique préthéra-
peutique.

ABSENCE DE RECOMMANDATION

Introduction

Il existe environ 2800 nouveaux cas de cancer du col de l'utérus par an avec un peu moins de 900 décès par an en France, pays où un dépistage est organisé jusqu'à 65 ans. Le premier pic d'incidence du cancer du col de l'utérus est aux environs de 45 ans mais il existe un second pic d'incidence entre 60 et 70 ans [636]. Environ 30 % des cancers du col utérin sont diagnostiqués après 65 ans mais comptant pour 53 % des décès par cancer du col [637-639]. La survie spécifique liée au cancer à 5 ans est de 38 % pour la population de plus de 75 ans contre 66 % (65-75 ans) à 82 % (15-44 ans) pour toutes les autres tranches d'âge (Invs 2008). Les données des autres pays occidentaux sont proches, par exemple la base de données américaine SEER montre que 21 % des cancers du col utérin sont diagnostiqués après 65 ans [640].

Les personnes âgées de plus de 65 ans atteintes d'un cancer du col utérin sont diagnostiquées à un stade plus avancé que les personnes plus jeunes : 54,8 % à un stade FIGO IB2-IVA et 33 % à un stade FIGO IVB pour les personnes de plus de 65 ans contre 33,7 % et 8,0 % pour

les moins de 45 ans en France [635]. Sur la base américaine SEER, on retrouve des chiffres à 42 % et 22 % respectivement pour ces stades pour les plus de 65 ans et 34 % et 13 % pour les moins de 65 ans, respectivement pour ces mêmes stades [640].

Pour les patientes atteintes d'un cancer du col utérin localement avancé (Stade IB2-IVA de la FIGO), seulement 29,2 % des patientes de plus de 65 ans reçoivent le traitement recommandé (i.e., radio-chimiothérapie concomittante et curiethérapie) contre 51,9 % à 66,1 % pour les différentes tranches d'âge de moins de 65 ans en France [639]. En miroir pour les stades précoces (traitement recommandé : chirurgie) et les stades métastatiques (FIGO IVB) (traitement recommandé : chimiothérapie), les pourcentages du respect des recommandations sont plus concordants entre les tranches d'âge [639].

L'évaluation onco-gériatrique préthérapeutique d'une patiente âgée permet d'évaluer les fragilités d'une patiente, qui sont un facteur de risque de mortalité et de complications de la séquence thérapeutique nécessaire au traitement du cancer. L'évaluation onco-gériatrique s'intéresse aux comorbidités, à l'autonomie, à l'environnement social, aux performances cognitives et à l'état nutritionnel de la patiente. Cette évaluation permet de classer les patientes en patientes non fragiles à traiter normalement, en patientes vulnérables et en patiente fragiles. Aucune étude spécifique au cancer du col utérin n'est disponible permettant de positionner l'évaluation onco-gériatrique chez une patiente âgée dans ce contexte. Il n'existe que des études évaluant l'intérêt de l'évaluation onco-gériatrique dans des cohortes de patientes atteintes de différents types de cancer. Deux études seulement ont montré que l'évaluation gériatrique a modifié la stratégie thérapeutique chez une patiente âgée dans 20 à 38 % des cas, notamment quand la patiente est dénutrie, quand il existe une altération du score ADL ou quand il existe des signes de dépression [667,668]. On peut également citer le score CRASH, qui intègre des variables gériatriques pour permettre d'estimer le risque de complications hématologiques ou non hématologiques de la chimiothérapie, indépendamment du type de cancer [644] et pouvant guider l'utilisation ou non de la chimiothérapie en cas de radiothérapie sur un cancer du col localement avancé.

Il n'existe pas de donnée pour savoir si l'évaluation gériatrique préthérapeutique a permis de modifier les taux de complications périopératoires ou la survie de manière significative dans une cohorte de patientes âgées atteintes d'un cancer en général ou d'un cancer du col utérin en particulier.

L'évaluation onco-gériatrique est faisable de manière générale (dans un contexte de cancer du col ou non). L'accès à une consultation onco-gériatrique peut parfois être difficile en fonction des contraintes de soins.

Il n'existe pas d'étude réalisée dans une population de personnes âgées atteintes d'un cancer du col de l'utérus pour la place d'une évaluation onco-gériatrique. Les seules données de preuve sont issues d'études de cohorte mélangeant plusieurs types de cancer. Seule une étude prospective, randomisée, multicentrique spécifique à la population des personnes âgées atteintes d'un cancer du col de l'utérus pourrait permettre de répondre à la question de manière plus robuste sur l'intérêt d'une évaluation onco-gériatrique sur la prévention de la morbidité péri-thérapeutique et l'amélioration de la survie.

Argumentaire

Pour appréhender la question PICO sur le bénéfice de l'évalu-
ation onco-gériatrique préthérapeutique pour un cancer du col utérin
chez une patiente âgée, il n'a pas été identifié d'étude spécifique aux
patientes atteintes d'un cancer du col utérin. Seules des études de
cohorte de patientes atteintes de plusieurs types de cancer montrent
que le plan thérapeutique prévu a été modifié dans 20 à 38 % des
cas, sans élément permettant d'affirmer que cette modification a
permis d'améliorer les complications péri-thérapeutiques ou la
survie.
**Synthèse** : au total, l'évaluation onco-gériatrique préthérapeutique chez une patiente âgée atteinte d'un cancer permet de modifier le schéma thérapeutique initialement prévu. Il n'existe pas de littérature spécifique au cancer du col permettant d'authentifier un gain sur les complications péri-thrapeutiques ou la survie. Les arguments utilisés pour orienter vers une consultation d'onco-gériatrie restent applicables, en particulier si la femme est âgée de plus de 75 ans ou si score G8 < 14.

**10.3.6. Question 130 :** Chez une patiente avec un prolapsus atteinte d'un cancer du col de l'utérus (P), la chirurgie (hystérectomie pour ablation de la tumeur) (I) versus la radiothérapie (C) permet-elle d'améliorer le pronostic (ou la survie) O ? (PICO 130)

**Recommandation 130**

Chez une patiente avec un prolapsus atteinte d'un cancer du col de l'utérus, les données actuelles de la littérature ne permettent pas d'émettre de recommandation sur le bénéfice de la chirurgie (hystérectomie pour ablation de la tumeur) comparée à la radiothérapie afin d'améliorer le pronostic ou la survie de ces patientes.

**ABSENCE DE RECOMMANDATION**

**Introduction**

Le prolapsus (hernie de l'utérus et du vagin au travers de la filière génitale) est une condition fréquente. Il est estimé que 11 % des femmes auront recours à la chirurgie pour prolapsus ou incontinence urinaire dans leur vie [669]. La coexistence d'un prolapsus et d'un cancer du col de l'utérus est une situation rare, dont l'incidence est estimée entre 0,14 % et 1 % [670]. Cette situation survient le plus souvent chez une patiente âgée, avec souvent des comorbidités associées, complexifiant la prise en charge.

Dans ce cas particulier d'une patiente avec un cancer du col utérin sur un prolapsus génital, il n'y a pas de standard de traitement évident : certains experts défendent la radiothérapie dans cette indication et d'autres la chirurgie. L'objet de la présente PICO est de déterminer si dans le cadre d'un cancer du col utérin diagnostiqué sur un prolapsus extérieurisé, la chirurgie permet un meilleur bénéfice en termes de survie par rapport à la radiothérapie.

La chirurgie chez une patiente atteinte d'un cancer du col utérin diagnostiqué sur un prolapsus utérin est a priori faisable (plusieurs cas cliniques dans la littérature) mais il existe une somme de cas particuliers rendant cette applicabilité peu reproductible. Cette faisabilité chirurgicale dépend de l'extension locale du cancer et l'atteinte des viscères adjacentes (vessie/rectum) et aussi de l'état général de la patiente (capacité anesthésique) mais cet état est le plus souvent compatible avec un geste sous anesthésie locorégionale.

La radiothérapie est également réalisable (plusieurs cas cliniques dans la littérature) mais il existe une somme de cas particuliers rendant cette applicabilité peu reproductible. Cette faisabilité de la radiothérapie dépend notamment de la capacité à réintégrer le prolapsus dans la filière génitale, ceci de manière prolongée pour permettre le balisage de la tumeur de manière reproductible lors de chaque séance de radiothérapie.

**Argumentaire**

Il n'existe pas d'étude randomisée réalisée dans une population de personnes atteintes d'un cancer du col de l'utérus sur un prolapsus génital, ni même de cohorte publiée suffisante. Il n'existe qu'une seule revue de la littérature complant les cas cliniques publiés et permettant d'apprêhender la question PICO.

Une étude prospective, randomisée, multicentrique paraît illusoire à développer pour répondre à la question posée par la PICO compte tenu de la faiblesse du nombre de cas de la situation clinique (cancer

du col utérin et prolapsus) et de la multitude de cas de figure clinique existants (prolapsus réintégrable ou non, comorbidité de la patiente, extension du cancer...). Un registre colligeant de manière exhaustive les différents cas de patientes prises en charge pourrait permettre de répondre en partie à la question posée par la PICO.

Il existe une somme de cas cliniques publiés dans la littérature rapportant l'expérience d'un centre dans le traitement d'un cas de cancer du col de l'utérus soit par radiothérapie soit par chirurgie, le plus souvent avec succès. Il existe une revue de la littérature publiée en 2016 par Matsuo K. et al. qui collige ces cas [671]. Cette revue de la littérature a identifié 157 articles dont 40 rapportent à la fois les modalités de prise en charge et les données de survie de ces patientes. Ces 40 articles concernent 78 patientes atteintes d'un cancer du col de l'utérus avec un prolapsus complètement extérieurisé dont 91 % sont publiés avant l'année 2000. La moyenne d'âge des patientes était de 63,7 ans (±13,3). Le cancer du col utérin était à un stade avancé au moment du diagnostic le plus souvent : la taille tumorale moyenne était de 8,9 cm (±5,7) avec 68,8 % des patientes avec une taille tumorale de plus de 4 cm lors du diagnostic. Le stade FIGO était supérieur ou égal à IB2 dans 45 % des cas mais dans 42 % des cas le stade FIGO n'était pas clairement rapporté (noté stade FIGO I sans plus de précision).

Le traitement réalisé était une radiothérapie seule dans 38,5 % des cas, une chirurgie seule dans 33,3 % des cas, l'association d'une chirurgie et d'une radiothérapie (dans cet ordre ou inversement) dans 28,2 % des cas. Quand une radiothérapie a été réalisée, elle était associée à une curiethérapie sauf dans le cas où l'hystérectomie était réalisée avant la radiothérapie. Concernant la chirurgie, elle était réalisée par voie vaginale dans 68,8 % des cas (33/48). Le geste d'hystérectomie était soit une hystérectomie simple soit une hystérectomie élargie. Un lymphadénectomie a été associée dans 14,6 % des cas.

Concernant la survie, les taux de survie sans récidive à 5 ans pour la chirurgie vs radiothérapie vs radiothérapie + chirurgie vs chirurgie + radiothérapie étaient de 85,1 %, 83,3 %, 81,4 % et 90,5 % (NS) respectivement, et le taux de survie globale spécifique au cancer de 70,6 %, 86,7 %, 85,6 % et 34,5 % (NS). En comparant les séquences thérapeutiques intégrant la chirurgie (chirurgie seule ou chirurgie avant ou après radiothérapie) versus radiothérapie seule, il existe une différence significative en multivariée pour la survie globale spécifique au cancer en faveur de la chirurgie : HR 0,32, IC 95 % 0,11-0,94, p = 0,039.

Concernant les modalités de traitement du prolapsus, celles-ci étaient peu rapportées dans les différents cas de la littérature, de même que leur devenir (récidive ou non).

La morbidité des différents traitements réalisés (chirurgie ou radiothérapie ou association) n'était pas rapportée dans cette revue de la littérature.

Depuis la publication de Matsuo K et al. en 2016, il existe une autre série de cas sur l'association cancer du col utérin et prolapsus publiée par Bacalbasa N et al. en 2020 en plus de quelques rares cas cliniques [672]. Cette série roumaine rapporte 11 cas de patientes avec cancer du col utérin sur prolapsus pris en charge entre 2014 et 2020. La moyenne d'âge de la population était de 68 ans et une parité moyenne de 5 enfants. Les 11 patientes ont été opérées par une hystérectomie avec lymphadénectomie par voie haute (après radiothérapie pour les 5 patientes ayant un diagnostic de cancer du col localement avancé). En termes de morbidité postopératoire, on note 3 cas de complications de grade 2 (infections urinaires le plus souvent). Cette publication de cohorte observationnelle ne rapporte pas de données de survie.

Les données publiées sur la place de la chirurgie ou de la radiothérapie chez les personnes atteintes d'un cancer du col de l'utérus sur un prolapsus sont rares et de niveau très faible (compilation de cas cliniques, pas de données de cohorte, même sur de petites cohortes). Chez les patientes atteintes d'un cancer du col de l'utérus sur prolapsus, la chirurgie associée ou non à la
radiothérapie semble permettre une meilleure survie globale spécifique que la radiothérapie seule chez les patientes atteintes d'un cancer du col de l'utérus sur prolapsus. Il est difficile d'évaluer la balance entre ces deux traitements en termes de complication ou de souhait des patientes.

**Synthèse** : chez une patiente atteinte d'un cancer du col utérin sur un prolapsus (P), il n'est pas possible d'émettre une recommandation de prise en charge. La prise en charge dépend de plusieurs facteurs : prolapsus réintégrable ou non, stade avancé ou non, et de l'état général de la patiente.

## Déclaration de liens d'intérêts

Henri Azaïs communique ponctuellement et fait partie du comité d'experts GSK, fait partie du comité d'experts IQVIA/SERB.

Sofiane Bendifallah est formateur conférencier pour INTUITIVE Surgical, orateur pour Gédeon Richter.

Geoffroy Canlorbe est formateur conférencier pour INTUITIVE Surgical.

Cyrus Chargari participe à des boards pour GSK, EISAI, MSD, recherche comme investigateur des essais thérapeutiques soutenus par TherAgulX et Roche, aide aux déplacements par IPSEN et Bayer.

Laurence Gladieff a perçu des honoraires institutionnels par GSK, Astra-Zeneca, MSD, PHARMAAND, REGENERON et une aide aux déplacements congrès par GSK, MSD, ABBVIE.

Cyrille Huchon est conférencier pour GSK et Gédéon Richter, et consultant pour Medtronic.

Martin Koskas a été conférencier pour Intuitive en 2021-2022, proctoring pour Intuitive en 2021-2022 et est conférencier pour GSK depuis février 2022.

Jean Levêque a été pour MSD vaccin de 2015 à 2020.

Alejandra Martinez a été conférencier pour MSD, GSK et ESAI.

Antoine Netter a été consultant pour Gédéon Richter en 2021-2022.

Charles-André Philip a été consultant colorants chirurgicaux pour Provephram en 2021-2022.

Pascal Rousset a effectué une intervention pour Bracco en mars 2022 ; il est conseiller pour Ziwig depuis 2021 et conseiller pour EDAP TMS France depuis juin 2022.

Isabelle Thomassi, est membre du board EUSOBI, présidente de la SIFEM, lecture rémunérées et participation ponctuelle à un board : General Electric, Siemens, Canon, Bard, Hologic, Guerbet, Fujifilm, Bracco, Bayer, iCAD, Incepto, GSK.

Cyril Touboul a été ou est consultant pour Intuitive, Besins, AB Medica, Conmed, AstraZeneca, GSK, MSD, General Electrics, Canon, Bionest, TBWA-ADELPHY.

Pauline Asseeva, Jean-Luc Brun, Xavier Carcopino, Pauline Chauvet, Abel Cordoba, Hélène Courcier, Yohann Dabi, Marion de Berti, Thomas Gaillard, Tristan Gauthier, Witold Gertych, Olivier Graesslin, Yohan Kerbage, Enora Laas, Aymeline Lacorre, Vincent Lavoué, Lise Lecointre, Fabrice Lecuru, François Margueritte, Paul-Jean Maternowski, Patrice Mathevet, Imane Menouer, Camille Mimoun, Anthony Moureau, Lobna Ouldamer, Claire Sanson déclarent ne pas avoir de liens d'intérêts.

## Supplément en ligne. Matériel complémentaire

Le matériel complémentaire accompagnant la version en ligne de cet article est disponible sur http://www.sciencedirect.com et https://doi.org/10.1016/j.gofs.2025.07.005.

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