The accuracy of renal tumor biopsy: analysis from a national prospective study.

OBJECTIVE: To assess preoperative renal tumor biopsy (RTB) accuracy. MATERIALS AND METHODS: As part of the prospective NEPHRON study, data from 1,237 renal tumors were collected, including the use and results of RTB and final histology following nephrectomy. During the 6 months period of inclusion, 130 preoperative biopsies were performed. We used the kappa coefficient of the McNemar test to determine the concordance between the biopsy and the nephrectomy specimen (NS) regarding four parameters: malignant/benign status, histological subtype, Fuhrman grade and microscopic necrosis. RESULTS: Preoperative biopsies were performed in 9.7 and 11.4 % of the 667 radical and 570 partial nephrectomies, respectively. Tumor biopsy was inconclusive in 7.7 % of the cases. In 117 cases, a comparison between RTB and NS was available. Benign tumors accounted for three (2.6 %) and five (4.3 %) of the RTB and NS, respectively (κ = 0.769, good). With seven (6 %) discordant results in terms of histological subtype characterization between RTB and final pathology, RTB accuracy was considered excellent (κ = 0.882). In 33 cases (31.7 %), Fuhrman grade was underestimated at biopsy resulting in an intermediate concordance level (κ = 0.498). Tumor microscopic necrosis was identified in 12 RTB (10.4 %) versus 33 NS (28.4 %) (κ = 0.357, poor). CONCLUSIONS: RTB provides good to excellent diagnostic performance for discriminating malignancy and tumor histological subtype. However, its performance is intermediate or even poor when considering prognostic criteria like Fuhrman grade or microscopic necrosis. Thus, this possible inaccuracy should be taken into consideration when using RTB for accurate guidance of treatment strategy.

[Contusions of the abdomen in children]. / Les contusions de l'abdomen chez l'enfant.

Marked progress in the treatment of abdominal contusions in children over the last few years is due to the development of conservative surgery to the spleen and even possible abstention from operation following splenic injuries. The reliability of paraclinical exploratory procedures has increased, and ultrasound and CT scan imaging have reduced the need for peritoneal puncture-lavage. However, and unresolved problem concerns associated visceral lesions, and although treatment of isolated splenic injuries is fairly well detailed that of hepatic lesions raises difficulties because of lack of data on exact location of lesions and the anatomical damage produced. Injuries provoked and treatment instituted are described in relation to children admitted for severe abdominal contusions between 1970 and 1985. Since 1984, 52 children have undergone initial ultrasound imaging and only 6 (8%) peritoneal puncture-lavage procedures were necessary. Ultrasound is of value for diagnosis of a hemoperitoneum but of very limited use for defining sites of lesions, a more refined diagnosis being established by computed tomography. Finally, routine simplified emergency intravenous urography is performed in any child with severe abdominal contusion with even microscopic hematuria to detect possible subadventitial rupture of renal artery.

[Experimental realization of a continent ileocolic valve in rats]. / Réalisation expérimentale d'une valve iléo-colique continente chez la rat.

The ileocecal valve plays a primordial role in pediatric digestive disorders. Various technical procedures have been proposed based on formation of an anastomosis with invagination of the distal extremity of the ileal segment into the colic portion. A resection of 20% of the small intestine and an ileocolic anastomosis were performed in the rat using three different methods: simple end-to-end ileocolic anastomosis, ileocolic anastomosis with invagination of ileal segment, and ileocolic anastomosis with ileal hemi-valve intubated into colon. Three animals died in the first group, the surviving three animals presenting massive reflux on barium meal examination. Of the 7 animals in the second group, 6 developed signs of occlusion from anastomotic stenosis. Two of the 10 animals the third group died, one before the 15th and one before the 40th day, as a result of anastomotic stenosis. Autopsy of the 8 survivors sacrificed after 3 months showed permeable anastomoses.

[Treatment of hydronephrosis in newborn infants. Apropos of 18 cases diagnosed by antenatal ultrasonography]. / Traitement de l'hydronéphrose du nouveau-né. A propos de 18 observations diagnostiquées par échographies anté-natales.

Results are reported of therapy of 18 neonates in whom obstetrical ultrasound imaging had demonstrated uni- or bilateral pyelo-caliceal dilatation due to stenosis of pyelo-ureteral junction (18 children--2 hydronephroses). Neonatal biologic, ultrasound and urographic examinations confirmed presence and assessed importance of the hydronephrosis. As a function of findings therapy consisted of immediate operation (10 neonates), delayed surgery (5 cases) or surveillance (3 cases). Severe uni- or bilateral forms, classified stage III or IV were operated upon immediately, sometimes as emergencies. Less severe cases (stage III) were operated upon after 1 to 3 months, and the minor forms (stage II) were the object of simple surveillance. The operative technique used for treatment of the hydronephros was the Andersson-Hynes operation, anastomosis in 9 cases involving microsurgical procedures. Emphasis is placed on the serious nature of these neonatal forms, often bilateral or associated with contralateral uropathy. In utero shunts during the antenatal period are excluded, therapy being decided after birth. Based on their experience, the authors underline the reliability of early microsurgical pyeloplasty which appears to be the operation of choice in neonates at the present time.

[Cavernous hemangioma of the bladder in children. Apropos of a case]. / Hémangiome caverneux de la vessie chez l'enfant. A propos d'un cas.

Benign tumours of the urinary bladder are very rare in children. A new case of cavernous haemangioma of the bladder is reported in a five year old boy presenting with macroscopic haematuria. This tumour is a hamartoma which usually presents with painless haematuria. In about 30% of cases, the bladder tumour is associated with angiomatous lesions in other parts of the body. The diagnosis may be suspected on intravenous urography or ultrasound examination, but it is generally made at cystoscopy. Biopsy and transurethral resection must be avoided because of the risks of haemorrhage. Partial cystectomy appears to be the most effective method of treatment.

[A new case of non-secreting adrenocortical tumor in a child]. / A propos d'un nouveau cas de cortico-surrénalome non sécrétant chez l'enfant.

Adrenocortical tumors are very rare, especially in their non secretory form. A 15 years old boy was hospitalized for evolutive fever since 6 weeks associated with asthenia and abdominal pain. Infections hematological, neurological and system diseases were eliminated. Abdominal ultrasonography reveal a poly-lobular mass adherent to the spleen and the posterior wall of the stomach. This is confirmed by fibroscopy and barium swallow. Abdominal scanner and scintigraphy did not give any new etiological argument. X Ray thorax is normal. Laparotomy reveals a retro-gastric mass adherent by its superior extremity to the spleen. A complete excision is done. The pathological examination shows all the histologic features of adrenocortical carcinoma. Its extension to the spleen grade this tumour with a height malignancy. No chemotherapy was undertaken, only a clinical, ultrasound and radiography observation with a follow up of 13 months.

[Gardner syndrome treated by total colectomy with preservation of the internal sphincter. Apropos of 3 cases]. / Syndrome de Gardner traité par colectomie totale avec conservation du sphincter interne. A propos de trois cas.

Familial polyposis and more particularly Gardner's syndrome is a difficult affection to treat in children, due to the risk of degeneration of polyps. Two factors are accepted by all authors as being of major importance: the need for early treatment to avoid degeneration; the advantage of maximum mucosal excision to avoid repeated follow up examinations and removal of further polyps from the remaining rectum. Three cases of familial polyposis and Gardner's syndrome were treated by either total colectomy and rectal mucosectomy (2 cases) or a partial Reifferscheid procedure (1 case). Two problems related to prognosis appear to be solved by this procedure: the need to operate on a child lacking clinical symptoms, and to obtain valid continence with a minimum of suveillance after surgery.

[Conservative treatment of esophagus ruptures and perforations. Esophageal diversion by minimal pharyngostomy]. / Traitement conservateur des ruptures ou des perforations de l'oesophage. Diversion oesophagienne par pharyngostomie a minima.

In ruptures or perforation of the oesophagus, the difficult choice between conservative methods (suture or drainage) and total exclusion of the organ can be avoided by minimal pharyngostomy. This procedure, which supersedes lateral oesophagostomy and makes use of an aspiration silicone-lined catheter to divert the oesophageal contents, is simple, rapid, effective and reversible. It is carried out in a region devoid of dangerous anatomical variants, in the avascular space below the greater cornu of the hyoid bone (a palpable landmark), the incision being made on the convexity of a curved clamp which pushes back the pharyngeal wall at the level of the sinus pyriformis. This technique has been used in 13 patients with satisfactory results.