Pathological response and safety of two neoadjuvant strategies with bevacizumab in MRI-defined locally advanced T3 resectable rectal cancer: a randomized, noncomparative phase II study.

BACKGROUND: In T3 rectal cancer (RC), preoperative chemoradiotherapy [5-fluorouracil (5-FU-RT)] reduces local recurrences, but does not affect overall survival. New therapeutic options are still necessary to improve clinical outcomes. PATIENTS AND METHODS: This randomized, noncomparative, open-label, multicenter, two arms, phase II study was conducted in MRI-defined locally advanced T3 resectable RC. In arm A, patients received 12-week bevacizumab plus 5-FU, leucovorin and oxaliplatin (Folfox-4) followed with bevacizumab-5-FU-RT before total mesorectal excision (TME). In arm B, patients received only bevacizumab-5-FU-RT before TME. Primary end point was pathological complete response (pCR) rate. RESULTS: Forty-six patients were randomized in arm A and 45 patients in arm B. In arm A, the rate of pCR was 23.8% [95% confidence interval (CI) 12.1% to 39.5%] statistically superior to the defined standard rate of 10%, P = 0.015. In arm B, the rate of pCR of 11.4% (95% CI 3.8% to 24.6%) was not different from 10%, P = 0.906. No death occurred during the study period, from the start until 8 weeks following surgery. Postoperative fistulas were reported for 16 patients (7 in arm A and 9 in arm B). CONCLUSION: Even if the addition of bevacizumab induced manageable toxicities including an increased risk of postoperative fistula and no treatment-related death, arm B did not achieve the expected pCR rate in the population of patients included. Induction bevacizumab-Folfox-4 followed by bevacizumab-5-FU-RT is promising. It is however necessary to continue investigations in the management of locally advanced RC. ClinicalTrials.gov Identifier: NCT 00865189.

[Brucellosis with hepatic lesions: A diagnosis to keep in mind]. / Brucellose avec abcès hépatiques : un diagnostic à ne pas oublier.

INTRODUCTION: Brucellosis is a rare infection in France and its wide spectrum of clinical presentation can be a diagnostic challenge. CASE REPORT: We report here the case of a 76-year-old Tunisian-born woman referred for fatigue, weight loss, intermittent fever, and pain in the right upper quadrant, along with hepatic lesions on CT-scan, MRI and PET-FDG suggesting malignant lesions. However blood cultures were positive to Brucella melitensis leading to a diagnosis of hepatic brucelloma. CONCLUSION: Hepatic abscesses are rare in brucellosis. This infection has to be evoked in patients coming from endemic areas even with atypical manifestations.

Transition zone and anterior stromal prostate cancers: Evaluation of discriminant location criteria using multiparametric fusion-guided biopsy.

PURPOSE: The purpose of this study was to evaluate precise location criteria on magnetic resonance imaging (MRI) to improve detection of transition zone (TZ) and anterior stroma (AS) prostate cancers using targeted MRI/transrectal ultrasound fusion biopsies as a reference standard. MATERIAL AND METHODS: Ninety-six men (mean age: 65 years±7.7 [SD] [range: 46-83 years]) with an elevated prostate-specific antigen (PSA) (PSA≥4ng/mL) who underwent standard and targeted biopsies on a TZ/AS suspicious lesion were included. The database was reviewed to assess topographical and morphological features of each suspicious lesion on MR images (T2-weighted anatomical images on 1.5T MRI or 3T) including PI-RADS score assessed by a senior radiologist. Histopathological examination of MRI-transrectal ultrasound fusion biopsy specimens was used as the reference standard. RESULTS: Ninety patients had a positive targeted biopsy with a median [IQR] lesion size of 16mm [13-20mm]. Homogeneous hypointensity on T2-weighted mages, lenticular shape, lack of capsule and indistinct margins were present in 77/90 (85%) patients. All TZ/AS prostate cancers were located in the anterior half of the prostate: 3% at the base, 69% in the mid gland and 28% at the apex. Lesions were mainly located close to or within the AS (74%) and more rarely laterally compressed close to the peripheral anterior horn. CONCLUSION: Our results suggest that specific topographic criteria of TZ and AS prostate cancers could add independent information to the usual diagnostic criteria in prostate MRI. Transrectal ultrasound fusion-targeted biopsies based on these specific criteria improve volume estimation of prostate cancers with substantial impact for prognosis and treatment planning.

[Persistent sciatic artery: possible false negative imaging]. / Artère sciatique persistante: possibles faux-négatifs de l'imagerie.

Persistent sciatic artery is a rare congenital malformation due to the lack of regression of the dorsal arterial axis of the embryo that can be revealed by serious complications. We report a case of bilateral persistent sciatic artery revealed by subacute distal ischemia. This case illustrates the possibility of false negative imaging and the importance of ruling out this diagnosis in case of recurrent and apparently idiopathic distal embolism.

Comparison of semi-automated and manual methods to measure the volume of prostate cancer on magnetic resonance imaging.

PURPOSE: The purpose of this study was to determine the accuracy of manual semi-automated and volumetric measurements to assess prostate cancer volume on multiparametric magnetic resonance imaging (MP-MRI) using whole-mount histopathology for validation. MATERIALS AND METHODS: We evaluated 30 consecutive men (median age, 65.7 years; interquartile range [IQR], 61.5-70.9 years) with a median prostatic specific antigen of 8.5ng/dL (IQR, 5.5-10.5ng/dL), who underwent MP-MRI before radical prostatectomy. Index tumor volume was determined prospectively and independently on the basis of MRI and whole-mount section volumetric assessment using the maximum histologic diameter (MHD) and the histologic volume (HV). The MRI index tumor volume was determined by two independent radiologists using a single measurement of the maximum tumor dimension (MTD), a simplified MR ellipsoid volume (MREV) calculation and a MR region of interest volume (MROV) segmentation displayed by a commercially available OsiriX®. MTD was compared to MHD, whereas MREV and MROV were compared to HV. RESULTS: Thirty index lesions (median HV, 1.514 cm3; IQR, 0.05-3.780 cm3) were analyzed. The MREV, MROV and HD were significantly correlated with each other (r>0.5). Inter-observer agreement for measurements was good for each method (r>0.780). The MTD was the best predictor of maximum histologic diameter (r=0.980 and 0.791) and had an excellent inter-variability correlation (P<0.0001). CONCLUSION: Prostate cancer histologic volume can be assessed using MREV or MROV with a good accuracy and low inter-observer variability. MTD has the lowest inter-observer variability and provides best degrees of correlation with MHD. MTD should be used on MRI for selecting and following patients for active surveillance and staging before focal treatment of prostate cancer.

Detection of c-Ki-ras mutation by PCR/RFLP analysis and diagnosis of pancreatic adenocarcinomas.

BACKGROUND: The c-Ki-ras oncogene (also known as KRAS2) is activated by point mutations involving codon 12 in 72%-100% of primary pancreatic adenocarcinomas, but the gene is not activated in nonneoplastic tissues. Therefore, the detection of c-Ki-ras mutations can facilitate the diagnosis of pancreatic adenocarcinomas, which are not always identified with current tests. Detection is usually performed by oligonucleotide hybridization combined with polymerase chain reaction (PCR), RNAse mismatch cleavage assay, or non-isotopic mismatched PCR, methods that are not feasible for routine screening of large numbers of samples because they are time consuming and/or expensive. PURPOSE: Our purpose was to evaluate a rapid, non-radioactive method of detection of a mutation in codon 12 of the c-Ki-ras gene in pancreatic tumor samples obtained by fine-needle aspiration for diagnostic screening. METHODS: Twenty consecutive patients (15 with pancreatic adenocarcinoma, one with pancreatic cystadenocarcinoma, one with endocrine islet cell tumor, and three with chronic pancreatitis) were selected for this study. A sample of pancreatic tissue from each patient with a tumor or pancreatitis was obtained and evaluated by fine-needle aspiration biopsy under computerized tomography scan or ultrasound guidance using a two-needle coaxial technique. Pancreatic DNA from each of these samples was evaluated by PCR amplification and restriction fragment length polymorphism (RFLP) analysis with nucleotide substitution in PCR primers, creating BstNI restriction patterns that distinguished mutated from normal alleles. The accuracy of the PCR/RFLP assay was validated with DNA from SW480 and HT29 colonic carcinoma cell lines with known mutated and wild-type c-Ki-ras gene sequences. Sensitivity was tested with a series of titration experiments. RESULTS: PCR/RFLP analysis can detect a mutation present in 1% of cells. No amplification could be performed in four (20%) samples because of the absence of cells in the aspirated sample. In the 16 samples adequate for PCR/RFLP analysis, a c-Ki-ras gene mutation was detected in 11 (92%) of 12 adenocarcinomas. Overall, diagnosis was obtained by pathologic (cytomorphologic) examination alone in 13 samples (81%). The presence of malignant cells and/or mutated c-Ki-ras gene was detected in 12 of 12 adenocarcinomas but not in chronic pancreatitis or islet cell tumor. CONCLUSION: Screening of pancreatic tissue samples obtained by fine-needle aspiration for c-Ki-ras mutation using PCR/RFLP analysis combined with pathologic examination could facilitate diagnosis of pancreatic tumors.

[Endovascular stent grafting for chronic proximal thoracic aortic pseudoaneurysm]. / Faux anévrysme chronique de l'aorte thoracique descendante proximale: traitement endovasculaire percutané.

Chronic descending aortic pseudoaneurysm generally result from traumatic and can spontaneously progress to rupture. We report the case of a 70-year-old patient presenting a chronic pseudoaneurysm of the thoracic aorta treated by endovascular stent-grafting. The patient underwent imaging evaluation for endoluminal repair: thoracic aorta was evaluated by contrast-enhanced CT scan and supra-aortic and iliac vessels were evaluated by MRI-imaging. Stent-graft was deployed under fluoroscopic guidance across the aneurysmal defect. The left sub-clavian artery was covered, but no ischemic symptoms appeared and transposition of the left sub-clavian artery was not necessary. Clinical and radiological follow-up at 6 and 30 months showed total exclusion and thrombosis of the pseudoaneurysm. Chronic pseudoaneurysm of the thoracic aorta do benefit from endoluminal repair, which is adapted to patients with high surgical risk.

Elephantiasis neuromatosa in neurofibromatis type I. MRI findings with review of the literature.

We report the case of a patient with NF-1 who presented with gross elephantiasis neuromatosa of her right leg. Prior to plastic surgery, Magnetic Resonance Imaging and Angiography (MRI and MRA) were performed to provide a detailed assessment of the extension as well as the vascular and muscular involvement of the neurofibroma.

["Heart, arteries and women" an innovative care pathway for women at high risk: First evaluation at one year]. / Le circuit « cœur, artères et femmes ¼ chez la femme à haut risque cardiovasculaire : première évaluation à un an.

INTRODUCTION: Cardiovascular diseases remain the first cause of death in women. To improve women's health cardiologists and gynaecologists should work together on women's specific cardiovascular risk factor. METHOD: Our study evaluated a care pathway named "heart, arteries and women". One hundred and ninety-one women were included for vascular (n=55) or hypertensive (n=136) explorations from January the first to December the 31st of 2013. We studied their clinical presentation and medical management. RESULTS: All women were at high cardiovascular risk (38% of them at very high risk). The average age was 52 years old. A woman on three had experienced high blood pressure or diabetes during pregnancy. One on two was postmenopausal woman. We stopped twelve estrogen-progesterone contraceptions; 60% didn't have gynaecological follow-up; 146 had high blood pressures (73% at night, 50% had no dipping blood pressure profile and 15 were newly diagnosed for hypertension). Sleep apnoea syndrome was suspected in half women. Medical therapies were optimized especially for women with atheroma in which 30 to 46% were properly treated (P=0.0005). Only 18% of the gynecologists received conclusive reports. CONCLUSION: At one year, our care pathway "heart, arteries and women" allowed to optimize medical therapy and clinical management. Everyone should be aware of this program.

Treatment of unresectable hepatocellular carcinoma with a combination of human recombinant alpha-2b interferon and doxorubicin: results of a pilot study.

Based on the in vitro and in vivo potentiation of the cytotoxic activity of chemotherapeutic agents by the interferons, a pilot study combining human recombinant alpha-2b interferon (IFN) and doxorubicin was conducted for the treatment of unresectable, histologically proven hepatocellular carcinoma. Between March 1988 and May 1990, 21 patients (median age: 60 years, range: 29-76) entered the study. The dose of doxorubicin was fixed at 35 mg/m2, every 3 weeks. The dose of alpha-2b IFN was 6 million U/m2 per day, 5 days a week. 3 patients (14%) obtained a partial response lasting 11, 16 and 30 months, and 1 had a stable disease during 8 months. The other 17 patients died within a median survival time of 4 months. All patients experienced flu-like symptoms. 7 patients experienced WHO grade III-IV haematological toxicity. We conclude that the association of alpha-2b IFN and doxorubicin is feasible, with respect to the use of doxorubicin at an inferior dose level than the same agent used without IFN. The response rate is comparable to that observed with doxorubicin used alone. Further phase I studies and randomised trials are required to confirm the role of this regimen in the treatment of unresectable hepatocellular carcinoma.

A new model of endovascularly induced renal artery stenosis in normocholesterolemic versus hypercholesterolemic rabbits.

RATIONALE AND OBJECTIVES: The authors determine the feasibility of creating renal artery stenosis by overdilatation and deendothelialization and compare the model in normocholesterolemic versus hypercholesterolemic rabbits. METHODS: Thirty male New Zealand White rabbits were randomized into two groups: group A (n = 15) was fed a normal diet and group B (n = 15) was fed a cholesterol-rich diet 4 weeks before stenosis induction. An aortogram was performed, then the right renal artery was overdilated with an angioplasty balloon-catheter, and deendothelialized. After 6 weeks, groups A and B were compared by angiographic and pathologic study. RESULTS: Comparison of group A versus group B showed that 12 arteries (80%) versus 6 (40%) were angiographically stenotic (P < 0.05); 14 (93%) versus 12 (80%) contained neointima (NS), 12 (80%) versus 3 (20%) showed medial disorganization (P < 0.01), and 9 (60%) versus 2 (13%) presented adventitial fibrosis (P < 0.01). CONCLUSIONS: A new model of endovascularly induced renal artery stenosis has been developed in rabbits. Medial proliferation and adventitial fibrosis are more frequent in normocholesterolemic rabbits.

Ventriculus terminalis of the conus medullaris: MR imaging in four patients with congenital dilatation.

MR findings in four patients with MR evidence of congenital cystic dilatation of the ventriculus terminalis were reviewed retrospectively. The ventriculus terminalis is a small cavity of the conus medullaris that forms during embryonic development as result of canalization and retrogressive differentiation. The dilated ventriculus terminalis appears on MR images as a small ovoid cavity with regular margination; intralesional fluid resembles cerebrospinal fluid on all MR sequences. After injection of contrast material, MR imaging shows no enhancement of the cyst or its wall, and thus differentiates congenital dilatation of the ventriculus terminalis from cystic tumors, which occur more frequently in this region.

Oral magnetic particles (ferristene) as a contrast medium in abdominal magnetic resonance imaging.

RATIONALE AND OBJECTIVES: In this phase III study, we evaluated the efficacy and safety of a negative contrast medium, ferristene (oral magnetic particles), among 277 patients undergoing magnetic resonance (MR) imaging of the abdomen. METHODS: Enhanced (800 ml ferristene) MR images were compared with unenhanced MR images in an intraindividual-patient control design. Adverse events were recorded. The examinations were performed on 1.5-T MR systems (T1- and T2-weighted sequences). RESULTS: Ferristene increased the diagnostic information in 50.9% of the patients, particularly in those with abdominal masses, lymphoma, or pancreatic disease. Distribution of ferristene in the stomach, duodenum, jejunum, and ileum was complete or sufficient in 70.5-85% of the studies. In 64% of the patients, we were confident in the MR findings after the use of ferristene, and ferristene disclosed additional findings in 22% of the patients. The incidence of adverse events was 9.0%, but only 3.6% of all patients experienced ferristene-related adverse events (e.g., nausea, vomiting). Most events were mild or moderate in intensity. CONCLUSION: Ferristene was well tolerated, and for 50% of the patients it added useful diagnostic information.

Value of fat-suppression gradient-echo MR imaging in the diagnosis of ovarian cystic teratomas.

Gradient-echo MR imaging (MRI) was evaluated for the diagnosis of ovarian mature cystic teratomas (MCTs). The FLASH technique was applied to T1-weighted images with and without fat suppression in 18 surgical operated patients with 19 MCTs, and findings were compared to those of conventional spin-echo (SE) T1-weighted-SE. Seventeen out of 19 MCTs were correctly diagnosed using FLASH and SE T1-weighted MR images with and without fat saturation. This study suggests that gradient-echo MRI can replace conventional SE T1-weighted MRI for the diagnosis of ovarian MCTs.

[Septic shock during the immediate post-partum period revealing a liver abscess in a woman with Crohn's disease]. / Choc septique au cours du post-partum immédiat révélant un abcès du foie chez une femme atteinte de maladie de Crohn.

Liver abscess is a rare complication of Crohn's disease. We report one case in a 27 year-old woman, presenting as a sepsis after delivery. Crohn's disease was quiescent at presentation. Pregnancy was the only predisposing condition. An intestinal fistula was diagnosed by ultrasonography. The patient was treated by antibiotics, bowel resection and surgical drainage of the abscess.

[Magnetic resonance imaging in the exploration of abdominal and anoperineal fistulas in Crohn's disease]. / L'imagerie par résonance magnétique dans l'exploration des fistules abdominales et ano-périnéales de la maladie de Crohn.

In a twelve month period, ten patients with fistulas related to Crohn's disease were explored by magnetic resonance imaging performed with a high-field supraconductive magnet. This technique demonstrated 3 cases of peri-anal abcesse invisible by other imaging modalities, and in 8 cases, fistules tracts, including 5 complex fistules, and one communicating with the bladder. This examination defined the extension of these lesions relative to the elevator plane, and demonstrated diffusion to the inferior space in 4 cases, to the superior space in 2 cases, and to both spaces in 2 cases. This method seems to be efficacious and does not expose the patient to X-rays.

[Cannabis and tobacco: cofactors favoring juvenile obliterative arteriopathy]. / Cannabis et tabac. Co-facteurs favorisant l'artériopathie oblitérante juvénile.

The causal effect of cannabis, associated or not with smoking, in juvenile thromboangiitis disorders such as Leo Buerger disease, has been suggested. We describe here a case of a 30-year-old woman who smoked cannabis and developed intermittent claudication of the lower limbs. Female sex and proximal localization of the lesions (external iliac artery) are not usually described in "cannabis arteritis". Cannabis would be involved not only in the pathogenesis of juvenile obstructive arteriopathy, but also in the development of atheromatous lesions in the young subject.

[Use of Gadolinium as a contrast agent in the course of renal arterial angioplasty]. / Utilisation du Gadolinium comme produit de contraste au cours d'une angioplastie des artères rénales.

For a 72-year-old patient with chronic renal failure, and a renal artery stenosis, we used gadolinium as a contrast agent to perform a digital subtraction arteriography and subsequent arterial angioplasty. Ten ml of gadolinium were used for the arteriography, and during a second procedure 40 ml for the angioplasty, giving high quality images. Renal function remained stable after the procedure, while blood pressure was easier to control.

[Investigation of peripheral vascular bed in critical lower limb ischemia: comparative study between arteriography and magnetic resonance angiography]. / Evaluation du réseau Jambier dans l'ischémie critique des membres inférieurs: comparison entre l'artériographie et l'angiographie par résonance magnétique (ARM).

OBJECTIVES: To determine the precise role of arteriography and contrast-enhanced magnetic resonance angiography (MRA) to evaluate the peripheral vascular bed in critical ischemia of the lower limbs in candidates for distal vascularization. MATERIAL AND METHODS: Fifteen patients (mean age 66 +/- 18 years) underwent MRA and arteriography. In all, 23 lower limbs were studied by non-selective arteriography with aortic injection (n=12) or selective arteriography with iliofemoral injection (n=11). RESULTS: The strength of agreement between MRA and selective arteriography was good (k=0.75) for analysis of leg arteries. MRA was better than non-selective arteriography (p<0.035) to evaluate artery patency. In our study, only MRA improved the treatment decision. CONCLUSION: In patients requiring an assessment of the peripheral vascular bed before distal revascularization, contrast-enhanced MRA can be the first exam. In case of an inadequate MRA, only selective arteriography needs to be performed.

[Glomus tumor of the extremities]. / Tumeur glomique des extrémités.

Glomus tumor is a neuro-myo-arterial benign tumor accounting for 1 to 5% of hand tumors which occurs principally in young adult females. It may be unique or multiple. Acute, focalized, pain is the main sign, the pressure of a small trigger zone induces a syncopal pain and immediate hand withdrawal. Differential diagnoses includes neurinoma, melanoma, hematoma, osteoid osteoma, fibrokeratoma, mucoid cyst, angioma, and exostosis. The diagnosis is suspected on clinical grounds, and X rays exhibits a bone erosion in one third of the cases. Magnetic resonance angiography is now the first line non invasive tool for both diagnosis and precise localization. Treatment consists in complete surgical tumor resection (J Mal Vasc 1999; 24: 364-367).