An anatomic study of deep inferior epigastric artery diameters at the origin from external iliac and at the lateral border of rectus abdominis muscle by computed tomographic angiography from autologous breast reconstruction patients.

BACKGROUND: Autologous breast reconstruction by means of microsurgical abdominal flaps is an very well described technique. The flap harvest dissection under inguinal ligament would cause the risk of parietal weakening in this zone and postoperative bulging. The goal of our study is to investigate whether the deep inferior epigastric artery diameter remains constant from its exit of the external iliac artery to its entrance in the rectus muscle sheath. PATIENTS AND METHOD: One hundred arteries were studied on fifty preoperative computed tomographic angiographies made before a DIEAP flap for breast reconstruction. We measured the caliber of the left and right deep inferior epigastric arteries at these two landmarks. The length of this artery between these was also calculated. This data were collected with specific angiography reconstruction. RESULTS: At the caudal landmark, the mean DIEA diameter was 2.1±0.27mm on the left side and 2.1±0.31mm on the right side. At the cephalic landmark, the mean DIEA diameter was 2.0±0.28mm on the left and 2.0±0.27mm on the right side (P=0.00035 at left side; P=0.0089 at right side). The mean pedicle length between the two landmarks was 22.3±2.85mm on the left side and 22.2±2.98mm on the right side. CONCLUSION: This computed tomographic angiography study showed that the diameter of DIEA is equivalent at its origin and at the lateral border of muscle. Flap harvest without dissection under inguinal ligament provides sufficient pedicle length and caliber to allow for comfortable and reliable sutures.

Renal manifestations of tuberous sclerosis complex: patients' and parents' knowledge and routines for renal follow-up - a questionnaire study.

BACKGROUND: Renal angiomyolipomas (AMLs) are a major clinical feature in patients with tuberous sclerosis complex (TSC). Spontaneous bleeding can be life threatening, and appropriate information and proper surveillance and management are important to limit morbidity and mortality. Because TSC is a rare disease, patients are at risk of suboptimal medical management. Our aim was to investigate patients' and parents' knowledge about renal angiomyolipomas (AMLs) in Tuberous Sclerosis Complex (TSC) and to identify current routines for renal follow-up. METHODS: A questionnaire survey was initiated by the French Reference Centre on TSC. It was distributed in France through university hospitals and the patients' association (2009-2011), and to patients registered by the Norwegian National Centre for Rare Epilepsy-Related Disorders (2013-2014). Contingency tables with Chi-Square test for independence (with Yates Continuity Correction) and Pearson-Chi-Square value were used for correlation statistics. RESULTS: We included 357 patients (France, n=257; Norway n=100). Most participants knew that TSC is associated with AMLs. However, 42 % did not know about the risk of AMLrelated bleeding, and 37 % had been informed about the risk of bleeding only after the age of 15 years. Furthermore, 14 % did not know whether they themselves or their child had AMLs. Patients had less knowledge than parents. Medical consultations and patient associations were the main sources of information. Among 30 % of patients, renal imaging was not received at all, or not conducted every 1-3 years, as recommended by current guidelines. Regular imaging was more frequent in patients with AMLs < 15 years, than in patients with AMLs ≥ 15 years. Ultrasound was the most frequently used imaging modality. CONCLUSIONS: Knowledge of renal AML in TSC patients and their parents was lower than expected, and follow-up by renal imaging was suboptimal for a substantial proportion of patients. Patients and parents should be informed about the risk and symptoms of renal bleeding, at the latest when the patient is 15 years. Monitoring the growth of AMLs should be standardized to comply with guidelines. Transition between adolescence and adulthood is a high-risk period and ensuring appropriate follow-up at this time is particularly important.

[Focal HIFU vs robot-assisted total prostatectomy: Functionnal and oncologic outcomes at one year]. / Traitement focal par HIFU versus prostatectomie radicale robot-assistée pour cancer de la prostate localisé : résultats carcinologiques et fonctionnels à 1 an.

OBJECTIVE: To analyse the functional and oncologic outcomes at one year of focal therapy with HIFU compared with total prostatectomy in patients with localised prostate cancer (PCa). PATIENTS AND METHODS: Retrospective and monocentric study from 2008 to 2014 comparing 2 cohorts of patients with localised PCa (T1/T2 clinical stage, Gleason score≤3+4=7 and PSA<15ng/mL), one treated by focal therapy (HIFU-F group), one by robot-assisted total prostatectomy (RATP group). Primary outcome was a trifecta defined as: absence of urinary incontinence, erectile function with sexual relations without treatment, negative PSA with negative surgical margins (RATP group) or negative biopsy cores (HIFU-F group). RESULTS: The 53 patients included in the "HIFU-F" group and the 66 patients in the "RATP" group were similar in terms of preoperative PSA, D'Amico risk group, erectile function but were different in terms of age, prostatic volume, length of cancer, Gleason score. Complication rate was not different. In multivariate analyse with propensity score, "HIFU-F" group achieved a better trifecta score than "RATP" group (OR=8,3, p=0,005). CONCLUSION: In case of low or intermediate risk localised PCa, "HIFU-F" group had better functional outcomes than initial learning curse "RATP" group, at one year. A long-term evaluation by a common endpoint is necessary to judge the oncological equivalence of both techniques. LEVEL OF EVIDENCE: 3.

CT and MR imaging features of mucinous tubular and spindle cell carcinoma of the kidneys. A multi-institutional review.

Mucinous tubular and spindle cell carcinoma (MTSCC) of the kidney is a recently identified renal malignancy. Diagnosis of this rare subtype of renal tumour can be challenging for pathologists, and as such, any additional data would be helpful to improve diagnostic reliability. As imaging features of this new and rare sub-type have not yet been clearly described, the purpose of this study was to describe the main radiologic features on computed tomography (CT) and magnetic resonance imaging (MRI), based jointly on the literature and findings from a multi-institutional retrospective review of pathology and imaging databases. Using a combination of CT/MRI features, diagnosis of MTSCC could be suggested in many cases. A combination of slow enhancement with plateau on dynamic contrast-enhanced CT/MRI, intermediate to high T2 signal intensity contrasting with low apparent diffusion coefficient values on MRI appeared evocative of this diagnosis. KEY POINTS: • A slow enhancement with plateau is observed either on CT or MRI. • High T2 signal components but low apparent coefficient diffusion are evocative. • T2-weighted imaging features depend on the mucin components of the tumour.

[Cryotherapy percutaneous for renal tumors: Our center's beginning experience]. / Cryothérapie pour les tumeurs rénales: le début d'expérience de notre centre.

OBJECTIVE: To evaluate oncologic and functional outcomes after percutaneous cryoablation (PCA) for renal masses based on our single center experience. PATIENTS AND METHODS: We retrospectively identified 26 patients who underwent PCA for 28 tumors between November 2006 and June 2011. Patient's demographics and baseline clinical characteristics, tumor features, perioperative information, and postoperative outcomes we rerecorded. A biopsy was performed systematically before each procedure. Control imaging was obtained at 1, 3, 6 and 12 months, and yearly thereafter. Oncological outcomes were determined by radiographic evidence of tumor recurrence, which was defined by contrast enhancement at the cryoablation site on control imaging at M3. RESULTS: Patients had mean age of 70.1 years, mean Charlson comorbidity index (CCI) and body mass index) were 6 and 29 kg/m(2) respectively. There were 11 kidney transplants, including 4 solitary. Mean tumor size was 29.5mm and was represented mainly by clear cell renal cell carcinomas (16/28), endophytic (17/28) and midkidney (14/28) (±9.8). Twenty-five cryoablations were performed percutaneously by two lumbotomy. Mean clearance preoperative MDRD was 66,1 mL/min. Mean length of stay was 3.3 days (±2.2). Intraoperative complications consisted of 2 pneumothorax and 6 minor complications postoperative (Clavien≤2). There were no major complications. Mean follow-up was 27.5 months (±15.7), MDRD clearance distance was 61.9 mL/min. Overall survival and disease-specific survival was 100%, while the recurrence-free survival was 78.6% (5 recurrences and 1 failure treatment). CONCLUSION: The percutaneous cryoablation provides a safe and oncologically to extirpative surgery for renal masses in patients with significant medical comorbidities. LEVEL OF EVIDENCE: 5.

Value of prostate multiparametric magnetic resonance imaging for predicting biopsy results in first or repeat biopsy.

AIM: To assess multiparametric magnetic resonance imaging (mp-MRI) in predicting prostate biopsy results. MATERIALS AND METHODS: Patients who underwent mp-MRI prior to prostate biopsy were prospectively included. The prostate was subdivided into 14 sectors and mp-MRI findings assessed using a five-level subjective suspicion score (SSS). Biopsy included targeted samples of abnormal sectors and systematic samples of normal peripheral zone sectors. RESULTS: Two hundred and eighty-eight patients were included [153 biopsy naïve, 135 with negative (n = 51) or positive (n = 84) prior biopsy]. Biopsy was positive in 168 patients. mp-MRI area under the receiver operating characteristic (ROC) curve (AUC) was 69.1% (95% CI: 67.1-70.9%), 72.5% (95% CI: 69.5-76%), and 73.8% (95% CI: 68.3-79.3%) at per sector, per lobe, and per patient analysis, respectively. At the per sector level, the AUC was significantly larger if detection was limited to cancers with a Gleason score of ≥7 (72.6%; 95% CI: 69.8-75.8%; p < 0.01) or ≥8 (87.1%; 95% CI: 78.3-95.7%; p < 0.01). mp-MRI performance was significantly influenced by prostate volume (p = 0.02), the presence of a concordant hypoechoic area (p < 0.001), but not by prostate-specific antigen (PSA) value, status of prior biopsy, or radiologists' experience. SSS was significantly associated with the Gleason score in true-positive lobes and patients (p < 0.0001). Using a SSS threshold of ≥3, cancer was missed in 13/102 lobes and 4/72 patients with cancers of Gleason score ≥7. CONCLUSION: mp-MRI provides a good detection of cancers with a Gleason score of ≥7 in candidates suitable for prostate biopsy.

[Anatomical study of muscular latissimus dorsi surface vascularized by the transverse branch of thoraco-dorsal artery]. / Étude anatomique du territoire musculaire du latissimus dorsi vascularisé par la branche transverse de l'artère thoraco-dorsale.

INTRODUCTION: The latissimus dorsi muscle flap is a type V according to Mathes and Nahai. It is vascularized by a proximal main pedicle represented by the thoraco-dorsal pedicle and pedicle distal accessory represented by the dorsal branches of the posterior intercostal arteries. The main thoraco-dorsal pedicle has a descending branch and a transverse branch. This anatomical study clarifies the muscular territory vascularized by the transverse branch of thoraco-dorsal artery for a secondary use after harvesting a thoraco-dorsal artery perforator flap or a muscle-sparing latissimus dorsi flap. MATERIAL AND METHODS: Our study focused on ten dissections latissimus dorsi muscle taken from five fresh cadavers chest, carried out within the University Department of Anatomy. The descending branch of thoraco-dorsal artery was ligated, the transverse branch was cannulated and injected with a mixture of barium sulfate/gelatin. After freezing, a static angiotomodensitometry (3D) of each flap was performed. RESULTS: The average muscular surface vascularized by the transverse branch is measured at 80% (77% minimum value, maximum value 83%) of the complete latissimus dorsi muscle. Intermuscular connections between the two branches of thoraco-dorsal pedicle were shown. CONCLUSION: The use of a ipsilateral latissimus dorsi muscle is a therapeutic option after harvesting a thoraco-dorsal artery perforator flap (TAP) or a muscle-sparing latissimus dorsi flap (MSLD-flap).

Salvage high-intensity focused ultrasound ablation for prostate cancer local recurrence after external-beam radiation therapy: prognostic value of prostate MRI.

AIM: To assess the prognostic value of magnetic resonance imaging (MRI) before salvage high-intensity focused ultrasound (HIFU) for locally recurrent prostate cancer after external-beam radiotherapy (EBRT). MATERIALS AND METHODS: Forty-six patients who underwent prostate MRI before salvage HIFU for locally recurrent prostate cancer after EBRT were retrospectively studied. HIFU failure was defined as a prostate-specific antigen (PSA) value >nadir + 2 ng/ml (Phoenix criteria) or positive follow-up biopsy or initiation of any other salvage therapy. The following prognostic parameters were assessed: neoadjuvant hormone therapy, clinical stage and Gleason score of recurrence, PSA level and velocity at HIFU treatment, and six MRI-derived parameters (prostate volume, tumour volume, extracapsular extension, seminal vesicle invasion, tumour extension into the apex or anterior to the urethra). RESULTS: Two factors were significant independent predictors of salvage HIFU failure: the PSA level at HIFU treatment (p < 0.012; risk ratio: 1.15, 95% CI: 1.03-1.29) and the tumour extension anterior to the urethra, as assessed by MRI (p = 0.046, risk ratio: 2.51, 95% CI: 1.02-6.16). CONCLUSION: The location of cancer recurrence anterior to the urethra on MRI is an independent significant predictor of salvage HIFU failure for locally recurrent prostate cancer after EBRT. Therefore, MRI may be useful for patient selection before post-EBRT salvage HIFU ablation.

Differentiation of transitional zone prostate cancer from benign hyperplasia nodules: evaluation of discriminant criteria at multiparametric MRI.

AIM: To assess topographical and magnetic resonance imaging (MRI) features in characterizing prostate transitional zone (TZ) nodules. MATERIALS AND METHODS: Two radiologists evaluated all TZ nodules visible at multiparametric MRI in 52 consecutive patients who underwent radical prostatectomy. The radiologists assessed topographical (anteroposterior and superior-inferior location, crossing of the sagittal midline) and T2-weighted (shape, presence and distinctness of capsule, distinctness of contours, presence of cysts) features, the apparent diffusion coefficient (ADC), and eight semi-quantitative and quantitative enhancement parameters derived from dynamic contrast-enhanced (DCE) imaging. The nature of the nodules was assessed using prostatectomy specimens. Five statistical methods taking into account multiple testing were used. RESULTS: One hundred and thirty-seven nodules (117 benign, 20 malignant) were evaluated. Mean ADC, all topographical, and all T2-weighted features were significant predictors of malignancy according to at least four out of the five statistical methods. Particularly, 20/20 and 18/20 cancers involved the anterior and apical third of the TZ, respectively. None of the enhancement parameters was significantly different between cancers and benign nodules. By assessing the presence of cysts, the nodules' capsule, and their anteroposterior and superior-inferior location, 111/117 benign nodules were correctly diagnosed, without misclassifying any cancer. CONCLUSION: Topographical, T2-weighted, and diffusion-weighted features can be used to characterize TZ nodules. DCE imaging does not seem to provide additional information.

[Preoperative computed tomographic angiography and perforator flaps: a standardization of the protocol]. / Angiotomodensitométrie préopératoire dans les lambeaux perforants: standardisation du protocole.

INTRODUCTION: Perforator flaps have an increasing role in reconstructive surgery. The preoperative analysis of perforator arteries enables the precise identification of their caliber and course, and so to select the optimal one(s), in order to improve the flap's design therefore reducing operating time. This study aims to propose a standardized protocol of computed tomographic angiography (CTA) before DIEAP flap, ALT flap, TAP flap and SGAP flap. MATERIALS AND METHODS: This study focuses on CTA before conducting a perforator flap. Together with radiologists, a CTA protocol has been developed. It specifies the patient's positioning, the intravenous contrast's concentration, flow rate, acquisition start and slice thickness as well as techniques used for mapping and 3D reconstruction. RESULTS: Patient positioning must be the same as the operating positioning during acquisition. His skin should be free of any cloth, clothing or bandages. The intravenous contrast must have a concentration between 350 and 400mg/ml for a flow rate of 4 ml/sec and its injection followed by a rinçure with 30 ml of saline water. The region of interest (ROI) should be defined for each flap. Its definition makes it to follow the contrast's progression through it. Acquisition begins when the contrast bolus arrives at the ROI. Slice thickness should be of 0.625 mm. CONCLUSION: CTA gives information on the caliber and the septal or intramuscular course of perforator as well as on its source vessel. By making a mapping of perforators, it prepares surgical procedure and dissection. The CTA protocol enhances reliability of perforator flaps.

[Does PCA3 score and prostatic MRI help selection of patients scheduled for initial prostatic biopsy?]. / Le score PCA3 et l'IRM prostatique permettent-ils de sélectionner les patients candidats a une première série de biopsies prostatiques ?

INTRODUCTION: Determinate if the adjunction of PCA3 score and/or prostatic MRI can improve the selection of the patients who have an indication of first prostate biopsy. PATIENTS AND METHODS: Multiparametric prostatic MRI and PCA3 score were made before biopsy to men scheduled for initial prostate biopsy for abnormal digital rectal examination and/or PSA superior to 4 ng/mL. T2-weighted imaging, diffusion-weighted imaging and dynamic contrast-enhanced imaging looked for suspect target classified on a scale of four. It was a prospective, single centre study. The diagnostic accuracy of PCA3 score and MRI was to evaluate in comparison with biopsy results. RESULTS: Sixty-eight patients were included, median PSA was 5.2 ng/mL (3.2-28). Negative predictive value (NPV) of MRI score 0, 1 and 2 were respectively 80%, 43% and 69%. Positive predictive value (PPV) of MRI score 3 and 4 were 50% and 81%. The PCA3 cutoff with best accuracy was 21 (Se: 0.91; Sp: 0.50). Only one patient with positive biopsy (0.5mm of Gleason score 3+3) had negative MRI and PCA3 inferior to 21. CONCLUSION: MRI and PCA3 score in association allowed, in this study, to consider reduction of unnecessary initial biopsy without ignoring potential aggressive tumor.

[Guidelines for the management of tuberous sclerosis complex renal disease]. / Atteintes rénales de la sclérose tubéreuse de Bourneville : recommandations de prise en charge.

PURPOSE: To review existing literature and deduce guidelines for the management of renal disease in patients with tuberous sclerosis complex (TSC). PATIENTS: After review of literature, a core panel of five physicians wrote a draft that was evaluated by 14 reviewers who used a 9-level scale (1: total disagreement; 9: total agreement). The guidelines were then reformulated until each item received a median score superior or equal to 8. RESULTS: Forty-eight to 80 % of TSC patients have significant renal involvement including angiomyolipomas (AMLs), cysts, malignant tumors and renal insufficiency. It is recommended to perform an abdominal ultrasound (and serum creatinine if abnormal ultrasound) when TSC is diagnosed. This work-up will be repeated every 3-5years if normal. Associated autosomal dominant polycystic kidney disease must be suspected in case of numerous and large cysts. After the age of 20, follow-up should use computed tomography (CT) or MRI that are more precise than ultrasound for the measurement of AMLs. Biopsy of a renal mass should be discussed in case of calcifications, necrosis or rapid growth. Females with TSC should undergo screening for pulmonary lymphangioleiomyomatosis by CT at the age of 18, and, if negative at the age of 30-40. Acute bleeding should be treated with percutaneous embolization. Asymptomatic angiomyolipomas with several risk factors (size>80mm, predominant vascular component, micro-aneurysms) should undergo prophylactic treatment, if possible using embolization. The role of mTOR inhibitors in the management of angiomyolipomas needs to be defined. CONCLUSION: Standardization of follow-up and treatment is necessary to improve the management of TSC renal involvement.

[HIFU for prostate cancer in patients with a history of severe colorectal disease]. / Cancer de prostate associé à une pathologie rectale sévère. Résultats préliminaires carcinologiques et fonctionnels du traitement par HIFU (Ablatherm).

OBJECTIVES: To report the functional and oncological outcomes of HIFU for prostate cancer in patients with a history of severe colorectal disease. METHODS: Between 2002 and 2009, 14 patients with a history of severe colorectal disease (cancer, lymphoma, inflammatory bowel diseases [IBD]) were treated with HIFU as a primary care option for localized prostate cancer. RESULTS: Mean age was 65.8 ± 6.1 years. Mean time between colorectal disease treatment and HIFU was 10.6 ± 6.8 years. The mean Prostate Specific Antigen (PSA) before HIFU was 12.1 ng/mL (4.5-55). Gleason score was inferior or equal to 6 in four patients (28.6%), equal to 7 in nine patients (64.3%) and superior or equal to 8 in one patient (7.1%). The mean prostate volume before HIFU was 22.1 ± 11.7 mL. The number of HIFU sessions per patient was 1.35. The mean nadir PSA was 0.61 ± 0.82 ng/mL. Systematic control biopsies were negative in seven patients (50%). Mean follow-up was 22 months with a 35.7% complication rate (three erectile dysfunctions, two urinary stress incontinences). No recto-urethral fistula occurred. CONCLUSION: HIFU was an interesting therapy for patients with a history of colorectal disease for whom regular treatment was challenging or non feasible.

[Outcomes of HIFU for localised prostate cancer using the Ablatherm Integrate Imaging® device]. / Traitement du cancer localisé de la prostate avec l'appareil Ablatherm Imagerie Intégrée® : résultats carcinologiques et fonctionnels.

OBJECTIVES: To report the functional and oncological outcomes of HIFU for prostate cancer using the Ablatherm Integrate Imaging(®) device. METHODS: Between January 2005 and June 2009, all patients treated with HIFU as a primary care option for localized prostate cancer and fulfilling the French Urological Association (AFU) guideline were included in this study. Validated questionnaires were used to assess continence, potencies and quality of life. RESULTS: A total of 297 patients met the inclusion criteria: 149 were low risk and 148 were intermediate risk according to d'Amico's risk group. The median prostate specific antigen (PSA) nadir was 0.12ng/ml with 65% of patients reaching a nadir less than 0.3 ng/ml. Systematic control biopsies were performed on 175 patients with 89% of negative biopsies. The disease free survival rate at 40 months was 79% for low risk group and 62% for intermediate risk group. The pre and post-HIFU treatment International Prostate Symptoms Score (IPSS) score and quality of life questionnaire were not statistically different. In the opposite, the pre and post-HIFU erection function and continence status were significantly different. CONCLUSION: Local control and Biochemical Free Survival Rate achieved with HIFU were similar to those expected with conformal external radiation beam therapy. Among the functional outcomes, potency was the most impacted by the treatment.

Candidates to salvage therapy after external-beam radiotherapy of prostate cancer: Predictors of local recurrence volume and metastasis-free survival.

PURPOSE: The purpose of this study was to assess the predictors of metastasis-free survival (MFS) and of the volume of the local recurrence in patients with rising prostate-specific antigen (PSA) serum level after radiotherapy for prostate cancer and referred for prostate magnetic resonance imaging (MRI) and biopsy in view of salvage treatment. MATERIALS AND METHODS: A total of 132 consecutive men (median age, 70 years; IQR, 66-77 years) with rising PSA after prostate radiotherapy who underwent prostate MRI and biopsy in view of salvage treatment between January 2010 and July 2017 were retrospectively evaluated at a single center. MFS predictors were assessed with Cox models. Predictors of the volume of the local recurrence (number of invaded prostate sectors at biopsy) were assessed using Poisson regression among variables available at PSA relapse. RESULTS: At multivariate analysis, an initial Gleason score≥8 (OR=7 [95% confidence interval (CI): 1.2-40]; P=0.03), a recent radiotherapy (OR=17 [95% CI: 3.9-72]; P<0.0001), the use of androgen deprivation therapy at PSA relapse (OR=12.5 [95% CI: 2.8-57]; P=0.001) and the number of invaded prostate sectors (OR=1.5 [95% CI: 1.1-2]; P=0.007) and maximum cancer core length (OR=0.7 [95%CI: 0.6-0.9]; P=0.002) at biopsy performed at PSA relapse were significant MFS predictors. The PSA level at relapse was significant independent predictor of the volume of local recurrence only when used as a continuous variable (P=0.0002) but not when dichotomized using the nadir+2 threshold (P=0.41). CONCLUSION: Pathological and clinical factors can help predict MFS in patients with rising PSA after prostate radiotherapy and candidates to salvage treatment. The PSA level at relapse has strong influence on the local recurrence volume when used as a continuous variable.