Value of Contrast-Enhanced Ultrasound Quantification Criteria for Identifying Patients not Responding to Bevacizumab-Based Therapy for Colorectal Liver Metastases.

PURPOSE: To evaluate changes in tumor vascularization parameters based on contrast-enhanced ultrasound (CEUS) quantification criteria of at least one visible liver metastasis as an early predictor of non-response to chemotherapy, including bevacizumab for colorectal cancer (CRC) liver metastases. MATERIALS AND METHODS: This multicenter prospective study included patients who received first-line bevacizumab-based chemotherapy. Tumor enhancement measured using CEUS within one liver metastasis and in relation to the surrounding healthy liver was quantified within 8 days before the first infusion of bevacizumab (E0), 24 hours after the end of the first infusion of bevacizumab (E1), in the 24 hours before the 2nd and 3 rd infusion of bevacizumab on day 15 (E2) and day 30 (E3), respectively, and after 2 months of treatment (E4). Endpoints were tumor response using RECIST criteria at 2 months, progression-free survival (PFS) and overall survival (OS). RESULTS: Among the 137 patients included in this study, 109 were analyzed. Only CEUS parameters calculated in relation to healthy liver were significant. High wash-in and wash-out rates at baseline were significantly associated with a better tumor response. Increases over time E2-E0 and E3-E0 for peak enhancement were significantly associated with shorter progression-free survival. Increases over time E2-E0 and E3-E0 for peak enhancement and wash-in area under the curve were significantly associated with a shorter overall survival. CONCLUSION: This large study demonstrated that early dynamic changes in the vascularity of liver metastases evaluated by quantified CEUS are associated with outcome in patients receiving first-line bevacizumab-based treatment for metastatic CRC.

Preoperative diagnosis of gangrenous acute cholecystitis: usefulness of CEUS.

PURPOSE: To evaluate CEUS for the preoperative diagnosis of gangrenous acute cholecystitis. SUBJECTS AND METHODS: This prospective study was approved by our institution's ethical committee. Fifty-six patients who underwent both US and CEUS and were confirmed as presenting with acute cholecystitis at pathology were included. Clinical data, mean time until surgery, macroscopic appearance of the GB, and the presence of gangrene at pathology were noted. Baseline US images and CEUS cine clips were analyzed by two experienced radiologists. Statistical analyses were performed. RESULTS: Gangrenous acute cholecystitis was diagnosed in 23 (41%) patients and uncomplicated acute cholecystitis in 33 (59%). Patients with gangrenous acute cholecystitis were found to be older (p = 0.048). Mean time from CEUS to surgery was found to be shorter in patients presenting with gangrenous acute cholecystitis (p = 0.052). At US, GB short axis ≥4 cm (p = 0.039) and GB wall interruption (p = 0.037) showed a statistically significant association with the diagnosis of gangrenous acute cholecystitis. On CEUS, discontinuous or irregular GB wall enhancement was reported in 19/23 (83%) patients with gangrenous acute cholecystitis and showed association with the presence of gangrene at pathology (p = 0.001). The interobserver agreement for the presence of discontinuous or irregular GB wall enhancement on CEUS images was good. CONCLUSION: Performing CEUS on patients presenting with US findings of acute cholecystitis is relevant, since the presence of a discontinuous or irregular enhancement of the GB wall appears to be correlated with the diagnosis of gangrenous acute cholecystitis.

Transfontanellar contrast enhanced ultrasound in infants: initial experience.

BACKGROUND AND PURPOSE: Transfontanellar contrast enhanced ultrasound (TCEUS) in infants with neurological diseases has not been previously reported. Thus, the objective of our study was to describe the imaging findings of transfontanellar contrast enhanced ultrasound (TCEUS) performed in various neurological conditions in infants and to compare the findings with non-enhanced transfontanellar ultrasound (TFUS) and MRI. METHODS: Local institutional review board approval was obtained and, because of the need to catheterize children for contrast media administration, written informed consent of parents was obtained prior to all performed TCEUS. Twelve infants who underwent 12 TCEUS were included in this study from June 2009 to June 2012. Second generation contrast material was used (Bracco). TCEUS imaging findings were compared with those of conventional transfontanellar ultrasound in each case and with MRI. RESULTS: In 10 out of the 12 performed examinations, TCEUS showed abnormalities which were not depicted on non-enhanced TFUS. Accurate diagnosis of TCEUS compared with MRI was found in 10 out of 12 initial TCEUS. No adverse events during or immediately after contrast media injection occurred. CONCLUSION: TCEUS appears to be a potential bedside accessible non-ionizing alternative imaging modality in the assessment of neonatal brain injury. It provides additional information when compared to non-enhanced transfontanellar US, especially in the field of brain perfusion assessment. Moreover, the information provided seems to be accurate when compared with those of MRI.

Visceral fat and clinical outcome in patients receiving first-line chemotherapy with bevacizumab for metastatic colorectal cancer.

BACKGROUND: Visceral fat produces angiogenic factors such as vascular endothelial growth factor that promote tumoral growth. However, its influence on outcome for patients with advanced cancer treated with anti-angiogenic agents is controversial. AIMS: The aim of this study was to determine whether visceral fat volume, visceral fat area and body mass index are associated with outcome in patients receiving first-line bevacizumab-based treatment for metastatic colorectal cancer. METHODS: This multicenter prospective study included 103 patients with metastatic colorectal cancer who received first-line bevacizumab-based chemotherapy. Computed tomography was used to measure visceral fat volume and visceral fat area. Endpoints were tumoral response at 2 months, progression free survival and overall survival. RESULTS: Visceral fat volume and visceral fat area, but not body mass index, were significantly associated with better outcome. Using sex-specific median values progression free survival was significantly longer in patients with high visceral fat volume (13.2 versus 9.4 months; p = 0.0043). In the same way, high visceral fat volume and visceral fat area were associated with a significantly better overall survival: 31.3 versus 20.5 months (p = 0.0072) and 29.3 versus 20.5 months (p = 0.0078), respectively. By multivariate analysis, visceral fat volume was associated with longer progression free survival and overall survival. CONCLUSION: This study demonstrates that a high visceral fat volume is associated with better outcome in patients receiving first-line bevacizumab-based chemotherapy for metastatic colorectal cancer.

Score to Predict the Occurrence of Pneumothorax After Computed Tomography-guided Percutaneous Transthoracic Lung Biopsy.

PURPOSE: The main objective of this study was to identify risk factors for post-percutaneous transthoracic lung biopsy (PTLB) pneumothorax and to establish and validate a predictive score for pneumothorax occurrence to identify patients eligible for outpatient care. MATERIAL AND METHODS: Patients who underwent PTLB between November 1, 2012 and March 1, 2017 were retrospectively evaluated for clinical and radiologic factors potentially related to pneumothorax occurrence. Multivariate logistic regression was used to identify risk factors, and the model coefficient for each factor was used to compute a score. Then, a validation cohort was prospectively evaluated from March 2018 to October 2019. RESULTS: Among the 498 eligible patients in the study cohort, pneumothorax occurred in 124 patients (24.9%) and required drainage in 34 patients (6.8%). Pneumothorax risk factors were chronic obstructive pulmonary disease (OR 95% CI 2.28[1.18-4.43]), several passages through the pleura (OR 95% CI 7.71[1.95-30.48]), an anterior biopsy approach (OR 95% CI 6.36 3.82-10.58]), skin-to-pleura distance ≤30 mm (OR 95% CI 2.25[1.09-6.65]), and aerial effusion >10 mm (OR 95% CI 9.27 [5.16-16.65]). Among the 236 patients in the prospective validation cohort, pneumothorax occurred in 18% and 8% were drained. A negative score (<73 points) predicted a probability of pneumothorax occurrence of 7.4% and late evacuation of 2.5% (OR 95% CI respectively 0.18[0.08-0.39] and 0.15[0.04-0.55]) and suggested a reduced length of hospital stay (P=0.009). CONCLUSION: This predictive score for pneumothorax secondary to PTLB has high prognostic performance and accuracy to direct patients toward outpatient management. CLINICAL TRIALS: NCT03488043.

Detection of interstitial lung disease in systemic sclerosis through partitioning of lung transfer for carbon monoxide.

BACKGROUND: Interstitial lung disease (ILD) is a leading cause of death in systemic sclerosis (SSc). Sensitivities and specificities of the current pulmonary function tests (PFTs) for the detection of ILD in SSc are poor. OBJECTIVE: To determine whether diffusion capacity of the lungs for carbon monoxide (DLCO) partitioned into membrane conductance for CO (DmCO) and alveolar capillary blood volume (Vcap) could provide more sensitive clues to ILD than current PFTs. METHODS: DmCO and Vcap were determined in 35 consecutive SSc patients in whom a cardiac and/or pulmonary vascular abnormality had been rejected according to the recommended screening algorithm. ILD was diagnosed with high-resolution computed tomography. RESULTS: Among 35 patients [6 men; median age (first-third quartile) 61.9 years (49.5-67.7)], 22 had no ILD and 13 did. Total lung capacity (TLC), vital capacity and DLCO [percentage of predicted value (%pred)] were lower in patients with ILD [86 (82-103) vs. 106 (98-112), p = 0.01, 96 (88-112) vs. 114 (104-121), p = 0.04, and 67 (59-81) vs. 80 (71-94), p = 0.02, respectively]. DmCO (%pred) and the ratio of DmCO to Vcap were much lower in patients with ILD [54 (48-72) vs. 83 (66-92), p < 0.001, and 0.22 (0.21-0.27) vs. 0.40 (0.35-0.53), p < 0.0001, respectively]. According to receiver operating characteristic analysis, the DmCO:Vcap ratio displayed higher sensitivity and specificity than TLC, vital capacity and DLCO in identifying ILD in our study group (p < 0.01). CONCLUSIONS: These results suggest that the partitioning of DLCO might be of interest for identifying ILD in SSc patients.

A challenging diagnosis of exercise-related transient abdominal pain.

A 17-year-old woman, high-performance triathlete, presented transient abdominal pain, face angioedema and sometimes syncope during exercise. Exercise-induced anaphylaxis was suspected at first. Allergic explorations with skin prick tests were negative but wheat flour specific IgE and recombinant rTri a14 (LTP) were weakly positive. However, wheat eviction did not improve the symptoms and stress test after wheat oral challenge did not show any signs of anaphylaxis. An abdominal ultrasound revealed peak expiratory velocities with a stenosis evaluated at 70 to 80 percent with turbulences in the celiac artery, confirmed by computed tomography angiogram. The diagnosis of exercise-induced median arcuate ligament syndrome (MALS) was retained and we discuss here the challenging diagnosis mimicking exercise-induced anaphylaxis.

Pulmonary and cutaneous sarcoidosis associated with interferon therapy for melanoma.

Interferon alfa is widely used as adjuvant therapy for melanoma. Numerous side effects have been attributed to interferon alfa. Interferon alfa-induced sarcoidosis is an uncommon event. We report the third case of pulmonary and cutaneous sarcoidosis in the course of interferon alfa treatment for melanoma. Most cases of sarcoidosis have been reported during treatment of chronic hepatitis C. The prognosis is good with discontinuation of treatment. Other than interferon therapy, sarcoidosis or granulomatosis reactions rarely have been reported in malignant melanoma. We discuss and review the literature on the physiopathology of sarcoidosis brought on by interferon therapy.

High-resolution CT predictors of hypersensitivity pneumonitis.

BACKGROUND: The purpose of this study was to evaluate the use of high-resolution chest computed tomography (HRCT) to distinguish hypersensitivity pneumonitis (HP) from other diffuse parenchymal lung diseases (DPLDs). METHODS: We examined 130 consecutive patients admitted to our hospital with DPLDs proved by HRCT. Patients underwent clinical and paraclinical examinations. Two readers interpreted 111 HRCT scans using predefined criteria. RESULTS: The findings in patients with HP were compared to those with other DPLDs (non-HP) by univariate and multivariate analyses. Five independent radiological predictors were identified and were given a weight according to their regression coefficient: ground-glass attenuation nodules (4 points), homogeneous ground-glass opacity (3 points), patchy ground-glass opacity (2 points), absence of adenopathy (2 points), and absence of linear/reticular patterns (2 points). A total score (that we called "diagnostic index") of 5 offered the best trade-off between sensitivity and specificity. At this point of the ROC curve, the sensitivity, specificity, and likelihood ratio were 74%, 90% and 7.7, respectively. Given a pre-test probability of HP of 34% (i.e., 38 HP / 111 patients), the post-test probability was 79%. CONCLUSION: Our results provide evidence that HRCT can accurately distinguish HP from other DPLDs.

A pulmonary nodule modeling tool as a diagnostic aid for lung HRCT images.

A lung model and a software tool were developed with the aim to help the radiologist in understanding the underlying nodule distribution modes in the lung, in spreading nodules on lung sections according to predefined distribution modes. For educational purpose lung elements can be easily highlighted using false colors. The fast execution times which allow the radiologist to test different nodule distributions and to choose, by comparison with CT, the likeliest one, makes it a helpful tool to determine the real diagnosis. Connected to a database containing final diagnoses, it should be a help for research in lung pathology.

Gemcitabine-Induced Pulmonary Toxicity: A Case Report of Pulmonary Veno-Occlusive Disease.

INTRODUCTION: Gemcitabine is a chemotherapeutic agent frequently used by for the treatment of several malignancies both in the adjuvant and metastatic setting. Although myelosuppression is the most adverse event of this therapy, gemcitabine might induce severe pulmonary toxicities. We describe a case of pulmonary veno-occlusive disease (PVOD) related to gemcitabine. CASE PRESENTATION: The patient was an 83-year-old man with a metastatic pancreatic cancer who was treated by gemcitabine as first-line therapy. He was in good health and received no other chemotherapy. A dose of 1000 mg/m(2) of gemcitabine was administered over a 30-minute intravenous infusion on days 1, 8, and 15 of a 28-day cycle. After a period of 6 months, a complete response was observed. Nevertheless, the patient developed a severe dyspnea, with arterial hypoxemia and very low lung diffusion for carbon monoxide. A CT scan showed diffuse ground glass opacities with septal lines, bilateral pleural effusion, and lymph node enlargement. On echocardiography, there was a suspicion of pulmonary hypertension with elevated systolic pulmonary artery pressure and normal left ventricular pressures. Right heart catheterization confirmed pulmonary hypertension and normal pulmonary artery occlusion pressure. Diagnosis of PVOD was made, and a gemcitabine-induced toxicity was suspected. A symptomatic treatment was started. At last follow-up, patient was in functional class I with near-normal of CT scan, arterial blood gases, and echocardiography. A gemcitabine-induced PVOD is the more likely diagnosis.

Cytomegalovirus-associated venous thromboembolism in renal transplant recipients: a report of 7 cases.

Renal-transplant recipients have a higher prevalence of thromboembolic events compared with the general population. This elevated risk has been attributed to immunosuppressive drugs as well as metabolic and immunologic factors. Cytomegalovirus (CMV) infection, a frequent complication of transplantation, is known to modify endothelial phenotype from anticoagulant into procoagulant. There are few reports addressing the association of venous thromboembolism with CMV infection in immunocompetent patients. Some authors have also reported cases of arterial thrombosis in transplant recipients presenting CMV infection. However, the association of venous thromboembolic events with CMV infection has not yet been discussed in these patients. We present seven cases of simultaneous acute CMV infection and venous thromboembolism in renal-transplant recipients and suggest a potential causative effect.

Significant increase in 1-year posttransplant renal arterial index predicts graft loss.

BACKGROUND AND OBJECTIVES: Conflicting data have been reported concerning the use of kidney graft arterial resistance index (RI) measured by Doppler to predict death-censored graft loss. We hypothesized that changes in RI values could carry better information than a single measure of RI. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Four hundred twenty-five renal transplant recipients were included in the study. We tested whether changes in renal arterial resistance index between 4 and 12 months after transplant (ΔRI(4→12)) were predictive of graft loss. RESULTS: Neither 4-month nor 1-year RI predicted graft loss. The area under the receiver operating characteristics curve of ΔRI(4→12) for graft loss was 0.75. A ΔRI(4→12) ≥10% had the best sensitivity and specificity. One year after transplant, 22% of the study population had ΔRI(4→12) ≥10%. Fifty-five patients (12.9%) experienced graft loss during follow-up. The annual incidence of graft loss was higher in patients with ΔRI(4→12) ≥10% (3.5 versus 1.3%; P = 0.009). In multivariate analysis, patients with ΔRI(4→12) ≥10% had an increased risk of graft loss (hazard ratio, 6.21; 95% confidence interval, 1.99 to 22.15; P = 0.002). CONCLUSIONS: A variation in RI ≥10% in the first year after transplant is an independent risk factor for death-censored graft loss in renal transplant recipients.

[Bronchial involvement in hypersensitivity pneumonitis]. / Atteinte des petites voies aériennes dans la pneumopathie d'hypersensibilité

Hypersensitivity pneumonitis is a respiratory disease resulting from the inhalation of antigens to which the exposed subject has been previously sensitized. Hypersensitivity pneumonitis is characterized by a diffuse and predominantly mononuclear cell inflammation of the alveolar regions that involves the small airways in most cases. It explains the presence of mosaic attenuation and expiratory air trapping at HRCT Scan. Chronic bronchitis, an obstructive defect at lung function tests and emphysema as long-term outcome are frequent consequences of this bronchial involvement.