Pietro Majno

University of Geneva, Genève, Geneva, Switzerland

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Publications (117)640.6 Total impact

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    ABSTRACT: In the treatment of early hepatocellular carcinoma (HCC), resection ablation and transplantation have had excellent initial success. Choices have to be based on a broad and long-term vision integrating-besides patients' interests-the community's needs and resources. In this scenario, guidelines such as the Barcelona Clinic Liver Cancer (BCLC) staging system can be viewed as a hideous frame (symbolized by the myth of Procrustes, Poseidon's son who stretched or maimed travelers to fit into his bed), or as a useful structure against which personalized or innovative treatments must be reality checked. In this article, the latter view is taken: For resection, portal hypertension must still represent a powerful caveat, particularly because of poor long-term results. Expansion of the criteria may instead be explored for multiple tumors and vascular invasion, where good indications can consistently be selected in expert surgical centers. For ablation, competitive results can be obtained although a small, but appreciable proportion of patients with early vascular invasion (∼ 10%), as they could probably benefit from anatomical resections. Conversely, ablative techniques overcoming the location and size limitations are developing and may prove competitive. For transplantation, several equivalent careful expansions of Milan's Criteria can be accepted, but as more patients have access to the waiting list-often prioritized on non-HCC indications-current allocation models prove to be insufficient, if not plainly inequitable, and should be revised.
    Seminars in Liver Disease 11/2014; 34(4):415-26. · 8.27 Impact Factor
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    ABSTRACT: The treatment of patients with metastatic rectal cancer remains controversial. We developed a reverse strategy, the liver-first approach, to optimize the chance of a curative resection. The aim of this study was to assess rectal outcomes after reverse treatment of patients with metastatic rectal cancer.
    Annals of Surgical Oncology 09/2014; · 4.12 Impact Factor
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    ABSTRACT: BC are a common source of morbidity after pediatric LT. Knowledge about risk factors may help to reduce their incidence. Retrospective analysis of BC in 116 pediatric patients (123 LT) (single institution, 05/1990–12/2011, medium follow-up 7.9 yr). One-, five-, and 10-yr survival was 91.1%, no patient died of BC. Prevalence and risk factors for anastomotic and intrahepatic BC were examined. There were 29 BC in 123 LT (23.6%), with three main categories: 10 (8.1%) primary anastomotic strictures, eight (6.5%) anastomotic leaks, and three (2.4%) intrahepatic strictures. Significant risk factors for anastomotic leaks were total operation time (increase 1.26-fold) and early HAT (<30 days post-LT; increase 5.87-fold). Risk factor for primary anastomotic stricture was duct-to-duct choledochal anastomosis (increase 5.96-fold when compared to biliary-enteric anastomosis). Risk factors for intrahepatic strictures were donor age >48 yr (increase 1.09-fold) and MELD score >30 (increase 1.2-fold). To avoid morbidity from anastomotic BC in pediatric LT, the preferred biliary anastomosis appears to be biliary-enteric. Operation time should be kept to a minimum, and HAT must by all means be prevented. Children with a high MELD score or receiving livers from older donors are at increased risk for intrahepatic strictures.
    Pediatric Transplantation 09/2014; · 1.50 Impact Factor
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    ABSTRACT: The optimal management of treatment for patients at intermediate risk of a common duct stone (including increased liver function tests but bilirubin <4 mg/dL and no cholangitis) is a matter of debate. Many stones migrate spontaneously into the duodenum, making preoperative common duct investigations unnecessary.
    JAMA The Journal of the American Medical Association 07/2014; 312(2):137-44. · 29.98 Impact Factor
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    ABSTRACT: Background During the last 20 years, relevant diagnostic procedures and advanced treatments have been progressively introduced in the management of hepatocellular carcinoma (HCC). The aim of the present study was to assess up-to-date survival trends for HCC in southern Switzerland, a region with one of the highest incidence rates in the country. Methods HCCs diagnosed in 1996–2009 were selected by the Ticino Cancer Registry. Cancer-specific survival (CSS) analysis was performed using the Kaplan–Meier method by calendar period: 1996–2000, 2001–2005 and 2006–2009. The log-rank test was used to detect differences in survival curves. Simultaneous assessment of prognostic factors was performed by a multivariate analysis using the Cox proportional-hazards regression model. Results 619 HCCs were analysed. There was a significant increase of patients undergoing transarterial chemoembolisation (TACE), whereas patients undergoing curative or palliative supportive treatments remained unchanged (p < 0.0001). No shift to earlier stages was detected. Significant differences in CCS were observed by age-group (p < 0.0001), diagnosis period (p < 0.0001), diagnosis technique (p = 0.0035), Barcelona-Clinic liver cancer stage (p < 0.0001), treatment (p < 0.0001). Multivariate analysis confirmed the independent impact on CSS of factors above mentioned, not including the diagnosis technique. Death risk was higher for patients diagnosed in 1996–2000 (HR: 1.32; 95% CI: 1.03; 1.68) and 2001–2005 (HR: 1.33; 95% CI: 1.05; 1.67) in comparison with 2006–2009 (reference group). Conclusions The current population-based report describes a major increase in HCC survival. Simultaneously an increased use of TACE has been detected, probable cofactor of the observed survival increase. Possibly additional efforts could be made to decrease the HCC stage at diagnosis through active surveillance of cirrhotic patients to allow an increase in curative treatments. For sure efforts should be made to comply with a standardised staging system for HCC, particularly for comparative population-based issues.
    Cancer Epidemiology. 01/2014;
  • Annals of surgery 12/2013; · 7.90 Impact Factor
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    ABSTRACT: Liver resection is generally restricted to patients without clinically significant portal hypertension (Hepatic Venous Pressure Gradient - HVPG - ⩽10 mmHg) and several teams perform transjugular HVPG measurements as part of the pre-operative work-up. The present study investigates whether a non-invasive Computed Tomography (CT)-based assessment could be as accurate as the invasive transjugular measurement. A cohort of patients with hepatocellular carcinoma (HCC) treated by resection (n=36) or transplantation (n=39) was selected (mean age: 61 ±9.2 years, male/female ratio: 4/1). Pre-operative CTs were read by two independent investigators, and potential CT-based HVPG predictors were compared to the transjugular HVPG measurements. A validation was conducted on another cohort of 70 non-surgical patients. The invasive HVPG values were significantly correlated to liver/spleen volume ratio, spleen volume, platelet count, and peri-hepatic ascites (p<0.001), which all showed high inter-observer agreements (intra-class correlation coefficients⩾0.927, Kappa⩾0.945). The presence of a HVPG>10 mmHg was best predicted by the liver/spleen volume ratio (AUC: 0.883 [0.805-0.960]) and the peri-hepatic ascites (p<0.001). These two variables were combined into an accurate model for predicting HVPG>10 mmHg (AUC: 0.911 [0.847-0.975]), with sensitivity, specificity, and positive and negative predictive values of 92%, 79%, 91% and 81%. The model was also accurate in the validation cohort with an AUC of 0.820 [0.719-0.921]. The proposed CT-based model showed a high accuracy in the prediction of HVPG and, if further confirmed by prospective validation, could replace the invasive transjugular assessment in patients not requiring a biopsy of the non-tumoral liver.
    Journal of Hepatology 12/2013; · 9.86 Impact Factor
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    ABSTRACT: Robotic surgery is an emerging technique for the management of patients with liver disease, and only a limited number of reports are available. A systematic search of electronic databases (PubMed, Embase and Cochrane), including only case series with more than five patients, identified nine series (with one from our institution), which totaled to 232 patients. Overall, the peri-operative outcomes of the reported patients are similar to those utilizing the laparoscopic and open approaches. Robotic surgery appears to be a valid option for selected hepatic resections in experienced hands. It could represent a bridge toward minimally invasive approaches for confirmed liver surgeons. By contrast, the long-term oncological outcomes remain uncertain and need further studies.
    Expert Review of Anti-infective Therapy 12/2013; · 2.07 Impact Factor
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    ABSTRACT: The vascular anatomy of the liver can be described at three different levels of complexity according to the use that the description has to serve. The first -conventional- level corresponds to the traditional 8-segments scheme of Couinaud and serves as a common language between clinicians from different specialties to describe the location of focal hepatic lesions. The second -surgical- level - to be applied to anatomical liver resections and transplantations - takes into account the real branching of the major portal pedicles and of the hepatic veins. Radiological and surgical techniques exist nowadays to make full use of this anatomy, but this requires accepting that the Couinaud system is a simplification, and looking at the vascular architecture with an unprejudiced eye. The third -academic- level of complexity concerns the anatomist, and the need to offer a systematization that resolves the apparent contradictions between anatomical literature, radiological imaging, and surgical practice. At this level, the number of second-order portal branches is variable and averages 20. We suggest naming this latter system the "1-2-20 concept", and submit that it fits best the average number of actual - as opposed to idealized - anatomical liver segments.
    Journal of Hepatology 11/2013; · 9.86 Impact Factor
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    ABSTRACT: In this review, the authors describe the management of patients with colorectal liver metastases in the era of effective chemotherapies and advanced interventional radiology. They give special attention to the surgical procedures that decrease the operative mortality and morbidity and produce clear margins. They discuss the best timing for chemotherapy, resection of the primary tumor, and resection of the liver metastases in an effort to improve long-term survival. The use of preoperative portal vein embolization, two-stage hepatectomy for bilobar synchronous liver metastases, and the liver-first strategy have allowed for treatment of patients with advanced disease with a curative intent, and to obtain 5-year overall survival of 30 to 60% despite poor prognostic factors and a cure (no recurrence at 10 years) in more than 20% of patients. These rates would have been unimaginable only two decades ago.
    Seminars in Liver Disease 08/2013; 33(3):262-72. · 8.27 Impact Factor
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    ABSTRACT: BACKGROUND: Stereotactic navigation technology can enhance guidance during surgery and enable the precise reproduction of planned surgical strategies. Currently, specific systems (such as the CAS-One system) are available for instrument guidance in open liver surgery. This study aims to evaluate the implementation of such a system for the targeting of hepatic tumors during robotic liver surgery. MATERIAL AND METHODS: Optical tracking references were attached to one of the robotic instruments and to the robotic endoscopic camera. After instrument and video calibration and patient-to-image registration, a virtual model of the tracked instrument and the available three-dimensional images of the liver were displayed directly within the robotic console, superimposed onto the endoscopic video image. An additional superimposed targeting viewer allowed for the visualization of the target tumor, relative to the tip of the instrument, for an assessment of the distance between the tumor and the tool for the realization of safe resection margins. RESULTS: Two cirrhotic patients underwent robotic navigated atypical hepatic resections for hepatocellular carcinoma. The augmented endoscopic view allowed for the definition of an accurate resection margin around the tumor. The overlay of reconstructed three-dimensional models was also used during parenchymal transection for the identification of vascular and biliary structures. Operative times were 240 min in the first case and 300 min in the second. There were no intraoperative complications. CONCLUSIONS: The da Vinci Surgical System provided an excellent platform for image-guided liver surgery with a stable optic and instrumentation. Robotic image guidance might improve the surgeon's orientation during the operation and increase accuracy in tumor resection. Further developments of this technological combination are needed to deal with organ deformation during surgery.
    Journal of Surgical Research 05/2013; · 2.02 Impact Factor
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    Christian Toso, Gilles Mentha, Pietro Majno
    Journal of Hepatology 04/2013; · 9.86 Impact Factor
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    ABSTRACT: INTRODUCTION: Heterotaxy designates rare congenital disorders of organ positioning in the thoracic and abdominal cavities, which can be associated with numerous anomalies, complicating the surgical management because of the loss of conventional anatomic landmarks. PRESENTATION OF CASE: A 72-year-old man was found to have asymptomatic cholestasis. Further workup included computed tomography and magnetic resonance cholangiopancreatography that revealed anomalies of lateralization of digestive organs associated with intestinal malrotation and polysplenia, and a stone-like element in the main bile duct. Endoscopic retrograde cholangiopancreatography failed to extract the lesion. Laparotomy found no stone, but a polypoid tumor with ampullary implantation. Pancreaticoduodenectomy was judged unreasonable due to the presence of macroscopic cirrhosis and a complete ampullectomy was performed. Histopathological examination revealed a hamartomatous polyp. DISCUSSION: The unusual angle of the duodenoscope in a left-sided duodenum may have contributed to the improper pre-operative diagnosis. Endosonography could have recognized the tissular origin of the lesion and prompted a more detailed preoperative planning. It was fortunate that the patient ended up receiving the appropriate treatment despite the absence of an adequate pre-operative diagnosis, as the option of performing an extended resection was ruled out due to the presence of cirrhosis. CONCLUSION: Although heterotaxy leads to increased technical difficulties in performing usual endoscopic and surgical procedures, it can be safely managed by experienced surgeons as illustrated by the present case. Imaging modalities have limited sensitivity in the diagnosis of small ampullary tumors. As false-negatives are likely to occur, this possibility should guide the choice of the best operation.
    International journal of surgery case reports. 03/2013; 4(6):544-546.
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    ABSTRACT: BACKGROUND: Several therapeutic strategies, such as ischaemic preconditioning, intermittent or selective pedicle clamping and pharmacological interventions, have been explored to reduce morbidity caused by hepatic ischaemia-reperfusion injury and the surgical stress response. The role of steroids in this setting remains controversial. METHODS: A comprehensive literature search in MEDLINE, Embase and the Cochrane Register of Clinical Trials (CENTRAL) was conducted (1966 onwards), identifying studies comparing perioperative administration of intravenous steroids with standard care or placebo, in the setting of liver surgery. Randomized Controlled trials (RCTs) and non-RCTs were included. Critical appraisal and meta-analysis were carried out according to the Preferred Reporting Items for Systematic reviews and Meta-analyses (PRISMA) statement. RESULTS: Six articles were included; five were RCTs. Pooling the results revealed that patients receiving intravenous glucocorticoids were 24 per cent less likely to suffer postoperative morbidity compared with controls (risk ratio 0·76, 95 per cent confidence interval 0·57 to 0·99; P = 0·047). The treated group experienced a significantly greater rise in early postoperative interleukin (IL) 10 levels compared with controls. In addition, steroids significantly reduced postoperative blood levels of bilirubin, and of inflammatory markers such as IL-6 and C-reactive protein. There was no evidence supporting a risk difference in infectious complications and wound healing between study groups. CONCLUSION: Perioperative steroids have a favourable impact on postoperative outcomes after liver resection. Copyright © 2013 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.
    British Journal of Surgery 01/2013; · 4.84 Impact Factor
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    ABSTRACT: Background The aims of this study were to assess sexual function and conjugal satisfaction in patients prior to and after liver transplantation, and in comparison to healthy individuals. Material and Methods A cross-sectional cohort questionnaire assessment was performed in adult liver recipients, including the International Index of Erectile Function (IIEF) for men or the Female Sexual Function Index (FSFI) for women. Conjugal satisfaction was assessed with the Locke-Wallace Marital Adjustment Test. Waitlist candidates and age-matched healthy individuals were used as controls. Results Questionnaires of 136 patients were assessed (45 women/91 men, mean age: 57±11 years). Overall, sexual function improved after transplantation (male: p=0.065 and female: p=0.072), but remained lower than in aged-matched healthy individuals. The post-transplant level of conjugal satisfaction was stable and similar to healthy controls in men, but improved significantly in women (p=0.008), with higher levels than in healthy subjects (p=0.05). Conclusions The present study shows that sexual function improves after transplantation, yet not to the level of healthy controls. It also demonstrates, for the first time, that post-transplant conjugal satisfaction is at least similar to the one of healthy controls.
    Annals of transplantation : quarterly of the Polish Transplantation Society. 01/2013; 18:136-45.
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    ABSTRACT: Obesity is associated with poor health outcomes in the general population, but the evidence surrounding the effect of body mass index (BMI) on postliver transplantation survival is contradictory. The aim of this study was to assess the impact of wait list BMI and BMI changes on the outcomes after liver transplantation. Using the Scientific Registry of Transplant Recipients, we compared survival among different BMI categories and examined the impact of wait list BMI changes on post-transplantation mortality for patients undergoing liver transplantation. Cox proportional hazards multivariate regression was carried out to adjust for confounding factors. Among 38 194 recipients, underweight patients had a poorer survival compared with normal weight (HR = 1.3, 95% CI: 1.13-1.49). Conversely, overweight and mildly obese men experienced better survival rates compared with their lean counterparts (HR = 0.9, 95% CI: 0.84-0.96, and HR = 0.86, 95% CI: 0.79-0.93 respectively). Female patients gaining weight over 18.5 kg/m(2) while on the wait list showed improving outcomes (HR = 0.46, (95% CI: 0.28-0.76)) compared with those remaining underweight. This study supports the harmful impact of underweight on postliver transplant survival, and highlights the need for a specific monitoring and management of candidates with BMIs close to 18.5 kg/m(2) . Obesity does not constitute an absolute contraindication to liver transplantation.
    Transplant International 12/2012; · 3.16 Impact Factor
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    ABSTRACT: BACKGROUND:: Liver-first reversed management (RM) for the treatment of patients with simultaneous colorectal liver metastases (CRLM) includes liver-directed chemotherapy, the resection of the CRLM, and the subsequent resection of the primary cancer. Retrospective data have shown that up to 80% of patients can successfully undergo a complete RM, whereas less than 30% of those undergoing classical management (CM) do so. This registry-based study compared the 2 approaches. METHODS:: The study was based on the LiverMetSurvey (January 1, 2000 to December 31, 2010) and included patients with 2 or more metastases. All patients had irinotecan and/or oxaliplatin-based chemotherapy before liver surgery. Patients undergoing simultaneous liver and colorectal surgery were excluded. RESULTS:: A total of 787 patients were included: 729 in the CM group and 58 in the RM group. Patients in the 2 groups had similar numbers of metastases (4.20 vs 4.80 for RM and CM, P = 0.231) and Fong scores of 3 or more (79% vs 87%, P = 0.164). Rectal cancer, neoadjuvant rectal radiotherapy, and the use of combined irinotecan/oxaliplatin chemotherapy were more frequent in the RM group (P < 0.001), whereas colorectal lymph node involvement was more frequent in the CM group (P < 0.001). Overall survival and disease-free survival were similar in the RM and CM groups (48% vs 46% at 5 years, P = 0.965 and 30% vs 26%, P = 0.992). CONCLUSIONS:: Classical and reversed managements of metastatic liver disease in colorectal cancer are associated with similar survival when successfully completed.
    Annals of surgery 11/2012; 256(5):772-779. · 7.90 Impact Factor
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    ABSTRACT: BACKGROUND: Although factors associated with an increased risk of recurrence after liver transplantation for hepatocellular carcinoma (HCC) have been extensively studied, the history of patients with a post-transplant recurrence is poorly known. METHODS: Patients experiencing a post-transplant HCC recurrence from 1996 to 2011 in two transplant programs were included. Demographic, transplant, and post-recurrence variables were assessed. RESULTS: Thirty patients experienced an HCC recurrence-22 men and 8 women with a mean age of 55 ± 6 years. Sixteen (53 %) were outside the Milan criteria at the time of transplantation. Most recurrences (60 %) appeared within the first 18 months after transplantation, ranging between 1.7 and 109 months (median 14.2 months). Mean post-recurrence survival was 33 ± 31 months. On univariate analysis, total tumor volume (TTV; p = 0.047), microvascular invasion (p = 0.011), and time from transplant to recurrence (p = 0.001) predicted post-recurrence survival. On multivariate analysis, both time from transplant to recurrence (p = 0.001) and history of rejection (p = 0.043), but not the location of the recurrence or the type of recurrence treatment, predicted post-recurrence survival. CONCLUSION: This study suggests that patients with early post-transplant HCC recurrence have worse outcomes. Those with a history of graft rejection have better survivals, possibly due to more active anti-cancer immunity.
    Journal of hepato-biliary-pancreatic sciences. 06/2012;
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    ABSTRACT: BACKGROUND. Surgical strategy for hilar cholangiocarcinoma often includes hepatectomy, but the role of portal vein resection (PVR) remains controversial. In this study, the authors sought to identify factors associated with outcome after surgical management of hilar cholangiocarcinoma and examined the impact of PVR on survival. Three hundred five patients who underwent curative-intent surgery for hilar cholangiocarcinoma between 1984 and 2010 were identified from an international, multi-institutional database. Clinicopathologic data were evaluated using univariate and multivariate analyses. Most patients had hilar cholangiocarcinoma with tumors classified as T3/T4 (51.1%) and Bismuth-Corlette type II/III (60.9%). Resection involved extrahepatic bile duct resection (EHBR) alone (26.6%); or hepatectomy and EHBR without PVR (56.7%); or combined hepatectomy, EHBR, and PVR (16.7%). Negative resection (R0) margin status was higher among the patients who underwent hepatectomy plus EHBR (without PVR, 64.2%; with PVR, 66.7%) versus EHBR alone (54.3%; P < .001). The median number of lymph nodes assessed was higher among the patients who underwent hepatectomy plus EHBR (without PVR, 6 lymph nodes; with PVR, 4 lymph nodes) versus EHBR alone (2 lymph nodes; P < .001). The 90-day mortality rate was lower for patients who underwent EHBR alone (1.2%) compared with the rate for patients who underwent hepatectomy plus EHBR (without PVR, 10.6%, with PVR, 17.6%; P < .001). The overall 5-year survival rate was 20.2%. Factors that were associated with an adverse prognosis included lymph node metastasis (hazard ratio [HR], 1.79; P = .002) and R1 margin status (HR, 1.81; P < .001). Microscopic vascular invasion did not influence survival (HR, 1.23; P = .19). Among the patients who underwent hepatectomy plus EHBR, PVR was not associated with a worse long-term outcome (P = .76). EHBR alone was associated with a greater risk of positive surgical margins and worse lymph node clearance. The current results indicated that hepatectomy should be considered the standard treatment for hilar cholangiocarcinoma, and PVR should be undertaken when necessary to extirpate all disease. Combined hepatectomy, EHBR, and PVR can offer long-term survival in some patients with advanced hilar cholangiocarcinoma. Cancer 2012. © 2012 American Cancer Society.
    Cancer 03/2012; 118(19):4737-47. · 5.20 Impact Factor
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    ABSTRACT: In many countries, the allocation of liver grafts is based on the Model of End-stage Liver Disease (MELD) score and the use of exception points for patients with hepatocellular carcinoma (HCC). With this strategy, HCC patients have easier access to transplantation than non-HCC ones. In addition, this system does not allow for a dynamic assessment, which would be required to picture the current use of local tumor treatment. This study was based on the Scientific Registry of Transplant Recipients and included 5,498 adult candidates of a liver transplantation for HCC and 43,528 for non-HCC diagnoses. A proportional hazard competitive risk model was used. The risk of dropout of HCC patients was independently predicted by MELD score, HCC size, HCC number, and alpha-fetoprotein. When combined in a model with age and diagnosis, these factors allowed for the extrapolation of the risk of dropout. Because this model and MELD did not share compatible scales, a correlation between both models was computed according to the predicted risk of dropout, and drop-out equivalent MELD (deMELD) points were calculated. CONCLUSION: The proposed model, with the allocation of deMELD, has the potential to allow for a dynamic and combined comparison of opportunities to receive a graft for HCC and non-HCC patients on a common waiting list.
    Hepatology 01/2012; 56(1):149-56. · 12.00 Impact Factor

Publication Stats

4k Citations
640.60 Total Impact Points

Institutions

  • 2000–2014
    • University of Geneva
      • • Department of Surgery
      • • Division of Transplantation
      • • Division of Gastroenterology and Hepatology
      Genève, Geneva, Switzerland
  • 2009–2012
    • Johns Hopkins University
      • Department of Surgery
      Baltimore, MD, United States
  • 2011
    • University of Alberta
      • Department of Surgery
      Edmonton, Alberta, Canada
  • 2009–2011
    • CRO Centro di Riferimento Oncologico di Aviano
      Aviano, Friuli Venezia Giulia, Italy
  • 2000–2009
    • Hôpitaux Universitaires de Genève
      Genève, Geneva, Switzerland
  • 2008
    • University of Maryland, Baltimore
      • Department of Surgery
      Baltimore, MD, United States
  • 2005
    • International Breast Cancer Study Group
      Berna, Bern, Switzerland
  • 1997–2003
    • Université Paris-Sud 11
      • Faculté de Médecine
      Paris, Ile-de-France, France
  • 1998
    • Hôpital Paul-Brousse – Hôpitaux universitaires Paris-Sud
      Île-de-France, France