Routine MRI With DWI Sequences to Detect Liver Metastases in Patients With Potentially Resectable Pancreatic Ductal Carcinoma and Normal Liver CT: A Prospective Multicenter Study.

OBJECTIVE: The purpose of this study was to evaluate the performance of systematic MRI with DWI for the detection of liver metastases (LM) in patients with potentially resectable pancreatic ductal carcinoma and normal liver findings at CT. SUBJECTS AND METHODS: Patients with potentially resectable pancreatic ductal carcinoma and a normal liver at CT were enrolled in a prospective multicenter study between March 2011 and July 2013 and underwent preoperative MRI. The reference standard was pathologic analysis of detected hepatic lesions. RESULTS: A total of 118 patients were enrolled. MRI depicted liver lesions that were not visible at CT in 16 patients. All lesions were visualized both with and without DWI. Lesions were LM in 12 (10.2%) patients and were confirmed in seven patients by preoperative biopsy, four by intraoperative frozen section, and one at 6-month follow-up evaluation after pancreatic resection. All but one liver metastatic lesion diagnosed with MRI were smaller than 10 mm. Four of 118 (3.4%) patients had a false-positive diagnosis of LM at MRI and remained LM free after a follow-up period of 24 months or longer. Three of 102 (2.9%) patients with normal MRI findings had subcapsular LM that were diagnosed intraoperatively. At follow-up, 99 of 118 (83.9%) patients were LM free after a mean of 24 months. The patient-based sensitivity of MRI for the detection of LM was 80.0% (95% CI, 51.9-95.7%); specificity, 96.1% (95% CI, 90.4-98.9%); positive predictive value, 75.0% (95% CI, 47.6-92.7%); and negative predictive value, 97.1% (95% CI, 91.6-99.4%). CONCLUSION: Compared with CT, preoperative MRI improves the detection of LM in patients with potentially resectable pancreatic ductal carcinoma and may change management and the rate of unnecessary laparotomy and pancreatectomy for 10% of patients.

Improving Surgical Resection of Metastatic Liver Tumors With Near-Infrared Optical-Guided Fluorescence Imaging.

Objective The aim of this study was to investigate the feasibility and future clinical applications of near-infrared (NIR) fluorescence imaging to guide liver resection surgery for metastatic cancer to improve resection margins. Summary Background Data A subset of patients with metastatic hepatic tumors can be cured by surgery. The degree of long-term and disease-free survival is related to the quality of surgery, with the best resection defined as "R0" (complete removal of all tumor cells, as evidenced by microscopic examination of the margins). Although intraoperative ultrasonography can evaluate the surgical margins, surgeons need a new tool to perfect the surgical outcome. Methods A preliminary study was performed on 3 patients. We used NIR imaging postoperatively "ex vivo" on the resected liver tissue. The liver tumors were preoperatively labelled by intravenously injecting the patient with indocyanine green (ICG), a NIR fluorescent agent (24 hours before surgery, 0.25 mg/kg). Fluorescent images were obtained using a miniaturized fluorescence imaging system (FluoStic, Fluoptics, Grenoble, France). Results After liver resection, the surgical specimens from each patient were sliced into 10-mm sections in the operating room and analyzed with the FluoStic. All metastatic tumors presented rim-type fluorescence. Two specimens had incomplete rim fluorescence. The pathologist confirmed the presence of R1 margins (microscopic residual resection), even though the ultrasonographic analysis indicated that the result was R0. Conclusions Surgical liver resection guided by NIR fluorescence can help detect potentially uncertain anatomical areas that may be missed by preoperative imaging and by ultrasonography during surgery. These preliminary results will need to be confirmed in a larger prospective patient series.

Development of a New Index to Assess Small Bowel Inflammation Severity in Crohn's Disease Using Magnetic Resonance Enterography.

Background: The severity of small bowel (SB) inflammation in Crohn's disease (CD) patients is a key component of the therapeutic choice. We aimed to develop a SB-CD Magnetic Resonance Enterography (MRE) index of Inflammation Severity (CDMRIS). Methods: Each gastroenterologist/radiologist pair in 13 centers selected MREs from 6 patients with SB-CD stratified on their perceived MRE inflammation severity. The 78 blinded MREs were allocated through balanced incomplete block design per severity stratum to these 13 pairs for rating the presence/severity of 13 preselected items for each SB 20-cm diseased segment. Global inflammation severity was evaluated using a 100-cm visual analog scale. Reproducibility of recorded items was evaluated. The CDMRIS was determined through linear mixed modeling as a combination of the numbers of segments with lesions highly correlated to global inflammation severity. Results: Four hundred and forty-two readings were available. Global inflammation severity mean ± SD was 21.0 ± 16.2. The independent predictors explaining 54% of the global inflammation severity variance were the numbers of segments with T1 mild-moderate and severe intensity of enhancement, deep ulceration without fistula, comb sign, fistula, and abscess. Unbiased correlation between CDMRIS and global inflammation severity was 0.76. Conclusions: The CDMRIS is now available to evaluate the severity of SB-CD inflammation. External validation and sensitivity-to-change are mandatory next steps.

CA9 level in renal cyst fluid: a possible molecular diagnosis of malignant tumours.

AIMS: The preoperative differentiation of malignant renal cystic tumours from benign lesions is critical, and it remains a common diagnostic problem. The aim was to examine if the Carbonic anhydrase 9 (CA9) level in cyst fluid can provide a molecular diagnosis of malignant cyst. METHODS AND RESULTS: Twenty-eight patients with a cystic renal mass were included. Fine-needle aspiration was performed to obtain the fluid. Postoperative pathology confirmed that there were 16 cystic renal cell carcinomas. Twelve benign cystic tumours were used as controls. One hundred microlitres of supernatant of cyst fluid was used to measure the CA9 protein level, which was measured by an enzyme-linked immunosorbent assay technique. CA9 was strongly detected and considered as positive in the cyst fluid of all 16 cystic malignant tumours (>1000 pg/ml), whereas its expression was negative in 11/12 benign cystic tumours (<300 pg/ml). The difference in percentages of positive CA9 between malignant and benign renal cystic tumours was significant (P < 0.001). CONCLUSION: The fluid of malignant cystic renal tumours contains a high level of CA9 protein. The measurement of CA9 level in cyst fluid may be used as a molecular diagnosis for differentiation between malignant and benign renal cystic masses.

Spontaneous splenic rupture in primary cytomegalovirus infection.

INTRODUCTION: Spontaneous splenic rupture is a rare occurrence in primary cytomegalovirus infection. CASES: We report two cases of spontaneous rupture of the spleen associated with primary cytomegalovirus infection in young immunocompetent adults. One patient had iron deficiency anemia, and the other a pyruvate kinase deficiency. Nonoperative management was successful in both cases. DISCUSSION: Nine other cases identified by a search of the medical literature are also reviewed. These cases do not show evidence of any particular risk factor.

Management of an Esojejunal Intrathoracic Leak Using an Endoscopic Vacuum-assisted Closure Technique.

Management of intrathoracic anastomotic leaks remains an important clinical challenge. We describe a case about a patient with intrathoracic esophageal anastomotic leaks after oesogastrectomy. Ndoscopic Vacuum-assisted closure technique today is an effective alternative in the treatment of anastomotic leaks after upper gastrointestinal tract surgery.

Difficult endoscopic diagnosis of a pancreatic plasmacytoma: Case report and review of literature.

A 71-year-old man, with history of plasmacytoma in relapse since one year, was hospitalized for a initial presentation of acute pancreatitis and hepatitis. Although there was a heterogeneous infiltration around the pancreas head, the diagnosis of an extramedullary localization of his plasmacytoma was not made until later. This delayed diagnosis was due to the lack of specific radiologic features and the lack of dilatation of biliary ducts at the admission. A diagnosis was made with a simple ultrasound guided paracentesis of the low abundance ascites after a transjugular hepatic biopsy, an endoscopic ultrasound-guided fine needle aspiration of the pancreatic mass, and a failed attempt of biliary drainage through endoscopic retrograde cholangiopancreatography. In order to document the difficulty of this diagnosis, characteristics of 63 patients suffering from this condition and diagnosis were identified and discussed through a systematic literature search.

True aneurysms of the pancreaticoduodenal artery: successful non-operative management.

BACKGROUND: True aneurysms of the pancreaticoduodenal arteries (PDA) are rare, often ruptured, and treated by operation with a high level of mortality. We review our experience since 1994 and that of the literature in the past 20 years to provide management guidelines for this uncommon clinical entity. About 100 cases of PDA aneurysms are described in the literature, most of them as case report. METHODS: Nine patients were admitted to our institution between 1994 and 2004 for true aneurysm of the PDA. They were analyzed with regard to the clinical presentation, radiologic findings, management, and outcome. RESULTS: Seven patients presented for sudden abdominal pain from retroperitoneal hemorrhage. In 2 patients PDA aneurysm was an incidental finding. Abdominal ultrasonography, computed tomographic scan, and visceral angiography was carried out in all cases. Aneurysms ranged from 4 to 30 mm (median, 16.5) in size. Celiac axis stenosis or occlusion was identified in 3 patients. One patient required emergent laparotomy for intra-abdominal rupture of a retro peritoneal hematoma. Therapeutic embolization was successful in all 9 patients. All except 1 are alive with no evidence of recurrence of the true PDA aneurysm with a mean follow-up of 59 months. CONCLUSIONS: The authors recommend definitive treatment of all true aneurysms PDA because of their high risk of rupture. Ruptured PDA aneurysms suspected on CT-scan requires emergent visceral angiography and selective embolization as definitive treatment.

[Pseudo-tumoral hepatic tuberculosis developing into a multinodular form despite treatment]. / Tuberculose hépatique pseudo-tumorale évoluant vers une forme multi-nodulaire malgré le traitement.

Localized macronodular tuberculosis of the liver is rare. In this location antituberculosis therapy results in a favorable clinical evolution in 100% of cases. We report a pseudo-tumoral form of this condition with no specific clinical, biological or radiological data. After ultrasound guided needle aspiration cytology suggesting metastasis, the correct diagnosis was obtained on liver biopsy after laparotomy. After what was probably inadequate therapy, the enlargement of several hepatic and splenic macronodules was observed. After two years and eight months, the clinical condition of the patient was good but radiological features remained. The risk of diagnostic errors and the therapeutic difficulties in the zones where the incidence of tuberculosis is low should be noted.

Rapid and sensitive detection of messenger RNA expression for molecular differential diagnosis of renal cell carcinoma.

PURPOSE: The aim of this study was to develop a practical technique to detect mRNA expression and to validate a panel of mRNA markers for molecular differential diagnosis of renal cell carcinoma (RCC). EXPERIMENTAL DESIGN: The renal cancer cell line SKRC-52 was used to set up the technique, which consisted of column extraction of RNA and one-step reverse transcription-PCR. We validated a panel of gene markers, including MN/CA9, cadherin-6, vimentin, mucin1, and parvalbumin, and studied 50 renal tumors (30 conventional, 9 papillary, and 5 chromophobe RCCs and 6 oncocytomas), 10 normal tissues, and 10 normal blood samples. We mimicked fine needle aspiration (FNA) biopsy in 10 kidneys with conventional RCC and applied this technique to 10 preoperative FNA samples from imaging-indeterminate renal tumors. RESULTS: The technique could detect as few as 10 SKRC-52 cells with MN/CA9 as mRNA marker and was less time consuming and labor intensive. MN/CA9 was a sensitive and rather specific gene marker for conventional RCC. Cadherin-6 gene expression was a sensitive marker for conventional and papillary RCC. Vimentin was highly specific for conventional RCC. Mucin1 mRNA was sensitive for papillary and chromophobe RCC and oncocytoma. Parvalbumin mRNA was a sensitive and highly specific marker for both chromophobe RCC and oncocytoma. Thus, these mRNA markers represent the biomarker genes for the subtypes of renal tumors. Finally, we successfully applied the technique to FNA specimens. Five preoperative FNA samples were MN/CA9 gene positive, suggesting a RCC, whereas the routine cytology was positive in only three cases. CONCLUSIONS: A rapid and sensitive assay of mRNA markers was developed for molecular differential diagnosis of RCC. This molecular assay can be used as a powerful ancillary to surgical pathological diagnosis and cytological diagnosis of RCC.

Thrombotic microangiopathy with liver, gut, and bone infarction (catastrophic antiphospholipid syndrome) associated with HELLP syndrome.

Hemolysis, elevated liver enzymes, low platelet count (HELLP) syndrome is a thrombotic microangiopathy complicating pregnancy and shares many clinical and biological features with thrombotic thrombocytopenic purpura (TTP) and hemolytic uremic syndrome (HUS). Thrombotic microangiopathy is also a pathological feature of catastrophic antiphospholipid syndrome (CAPS). An association between refractory HELLP syndrome and antiphospholipid syndrome (APS) has been reported in a few cases. We describe a 19-year-old woman with APS and multiorgan failure conforming to a diagnosis of CAPS who developed refractory HELLP syndrome.

Fine needle aspiration biopsy of complex renal cystic tumors in the era of modern imaging modalities: where shall we go?

OBJECTIVE: To report on a series of fine needle aspiration (FNA) biopsies for preoperative diagnosis of complex cystic renal mass. STUDY DESIGN: From August 2002 to February 2009, 32 patients with a complex cystic renal mass were studied. Tumor size ranged from 1.5-7.7 cm, with a median of 3.0 cm. Bosniak classification was 15 IIF, 12 III, and 5 IV. FNA biopsy was performed under CT guidance to obtain the fluid. Malignant and suspect cytological reports were considered as a positive diagnosis, and absence of epithelial cells as a negative diagnosis. RESULTS: Sufficient fluid was obtained in all cases. A positive preoperative diagnosis was found in 11 patients, and 21 cysts presented as absence of epithelial cells. Of the 26 patients who underwent surgery, pathology proved that there were 21 malignant and 5 benign cysts. Among the operated patients with a malignant cystic tumor, 11/21 (52.3%) presented a negative preoperative diagnosis. One preoperative positive diagnosis was proved to be a benign cyst. The accuracy of preoperative positive cytology was 10/11 (90.9%). CONCLUSION: No difficulty was noticed in obtaining the fluid by FNA of a cystic small renal mass. A false negative diagnosis was due mainly to the absence of malignant cells in the fluid of cysts. Biomarkers in fluid shall be studied to solve the diagnostic problem.

Vasculitis of the bladder: An extremely rare case report.

INTRODUCTION: Isolated vasculitis of the bladder is extremely rare. The main causes of which are auto-immune diseases and occasionally infections. Corticosteroid therapy plays a central role in treatment in the majority of cases. PRESENTATION OF CASE: We report a case of gross hematuria associated with irritative low urinary tract symptoms (LUTS) and an increase of biological parameters of inflammation. Radiologic studies suspected a pelvic tumor process. We performed a cystoscopy with multiple biopsies. The pathological findings of the chips were in favor of a thrombotic nongranulomatous vasculitis of small and medium caliber. In view of these findings, all systemic diseases and inflammatory diseases such as cryoglobulinemia, the anti-phospholipid syndrome, Crohn's disease were eliminated. The symptoms regressed completely under antibiotics and anticoagulants. DISCUSSION: Our treatment options were based on the extent of the acute phase reaction and the pelvic venous thrombosis. A few similar cases have been reported in the literature, particularly a case of isolated necrotizing vasculitis of the bladder involving small vessels with a mild laboratory acute phase reaction which was treated with corticosteroids and cyclophosphamide. CONCLUSION: It is important to differentiate this rare pathological feature of the bladder from other bladder tumors as the treatment is medical rather than surgical.

Combination of core biopsy and fine-needle aspiration increases diagnostic rate for small solid renal tumors.

AIM: Our aim was to evaluate the performance of combination of fine-needle aspiration (FNA) and core biopsy (CB) as a method for the diagnosis of small solid renal tumors. PATIENTS AND METHODS: Ninety patients with a radiologically detected small solid renal tumor (≤ 4 cm) underwent a biopsy. Patient underwent FNA (FNA group, n=32) or CB (CB group, n=30) or combination of both FNA and CB (combination group, n=28). The diagnostic rate and accuracy of both techniques were assessed. RESULTS: The diagnostic rate of the combination group (92.9%) was superior to that of the FNA group (62.5%) and CB group (76.7%) (p=0.006, and p=0.147, respectively). In the combination group, 11 CBs were diagnostic with 13 nondiagnostic FNAs, while 4 FNAs were diagnostic with 6 nondiagnostic CBs. For tumors ≤ 2 cm, the combination of FNA and CB significantly increased the diagnostic rate, compared with FNA alone (p=0.033) and CB alone (p=0.044). The accuracy for FNA, CB and the combination of FNA and CB was 88%, 100% and 100%, respectively. CONCLUSION: The combination of FNA and CB increased the diagnostic rate of renal biopsy for the small solid renal tumors.

The use of MN/CA9 gene expression in identifying malignant solid renal tumors.

OBJECTIVE: Small solid renal tumors are increasingly encountered. It is important to determine the malignancy of solid renal tumors for the choice of treatment. MN/CA9 is expressed in malignant renal cells but absent in normal cells. MN/CA9 is one of the most powerful gene markers available for RCC. The objective of this pilot study is to utilize MN/CA9 gene expression in FNA biopsy to determine the malignancy of imaging-indeterminate solid renal tumors. METHODS: A total of 35 patients with an imaging-indeterminate solid renal mass entered into this study. The molecular protocol consisted of a rapid column extraction of RNA and one-step RT-PCR for the detection of MN/CA9 gene expression. The preoperative molecular diagnosis was compared with postoperative pathology. RESULTS: There were 28 RCCs (19 clear cell carcinomas, 7 papillary carcinomas and 2 chromophobe carcinomas) and 7 benign tumors proved by postoperative pathology. The overall sensitivity and specificity for MN/CA9 were respectively 68% and 100%. MN/CA9 was positive in 16/19 (84%) FNA biopsies of clear cell RCCs. No false positive appeared for MN/CA9 gene expression. Moreover, MN/CA9 gene expression was positive in 8/13 (62%) of false negative or suspect cytology. CONCLUSION: Detection of MN/CA9 gene expression in FNA biopsy is possible. Its detection can be helpful in identifying the malignancy among renal tumors.

Characteristics of image-detected solid renal masses: implication for optimal treatment.

BACKGROUND: Solid renal masses are found increasingly. Further analysis of the characteristics of solid renal masses is useful for optimal treatment. METHODS: A retrospective analysis of all solid renal masses was conducted from December 1998 to May 2003 at the Urology Department, Central University Hospital of Saint-Etienne, France. A total of 162 solid renal masses were treated. The preoperative imaging diagnosis of ultrasound and computed tomography, and final pathological results were reviewed. RESULTS: One hundred and forty-five tumors were pathologically confirmed to be renal cell carcinomas (RCC); 17 tumors (10.5%) were benign. There were eight renal oncocytomas, eight renal angiomyolipomas and one benign mixed epithelial/stroma tumor. Three oncocytomas and five angiomyolipomas were strongly suspected before surgery. The majority of the benign tumors were < or =4 cm. The percentage of small benign tumors (< or =4 cm) was significantly higher than large benign tumors (>4 cm). Although it is possible to use imaging to detect some benign tumors, the majority of benign tumors cannot be diagnosed definitively by imaging before surgery. CONCLUSIONS: Malignancy in solid renal masses is tumor-size related. Benign solid renal tumors appear mainly as small-sized tumors. The preoperative differentiation between an RCC and a benign tumor can be difficult. Our data suggest that a biopsy is necessary in selected patients to achieve the maximum accuracy in order to provide optimal treatment.