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.

[Eight years of experience in robot-assisted partial nephrectomy: oncological and functional outcomes]. / Huit ans d'expérience en néphrectomie partielle robot-assistée: résultats carcinologiques et fonctionnels.

INTRODUCTION: Partial nephrectomy (PN) is currently the reference treatment for renal tumors of less than 4 cm in size (T1a). Laparoscopic PN is difficult to perform, with the main consequence being an increase in warm ischemia time and morbidity. In facilitating the surgical procedure, robotics combines the benefits of minimally invasive and conservative surgery. We report here 8 years of experience with 110 robot-assisted partial nephrectomies (RAPN). The objective of this study was to analyze the oncological and functional outcomes. PATIENTS AND METHODS: Between March 2005 and September 2012, 110 patients underwent RAPN. The epidemiological and surgical data and the oncological and functional outcomes were retrospectively collected and analyzed. RESULTS: Seventy-six men and 34 women underwent surgery. The mean age was 59.6 ± 14.2 years. Mean operative time was 141.3 ± 36.1 minutes with a warm ischemia time of 21.2 ± 8.8 minutes. Mean hospital stay was 5.3 ± 2.2 days. Mean tumor size was 27.4 ± 9.8mm with 82.7% malignant tumors, of which 62.7% were clear cell carcinomas. Surgical margins were healthy in 100% of cases. After a mean follow-up of 28.7 ± 18.5 months, no recurrence was noted. On a functional level, there was no short-term or medium-term impairment of renal function. The frequency of postoperative complications was estimated as 12% including 7% of surgical complications (3 arterial pseudoaneurysms, 4 episodes of bleeding from the cut surface and 1 conversion to laparotomy). CONCLUSION: Robotics brought surgeon dexterity, meticulousness and precision. These qualities are essential in conservative renal surgery and made RAPN a safe and effective technique that gives good short and medium-term oncological and functional results.

[Robotic assisted laparoscopic living donor nephrectomy: preoperative assessment and results of 100 cases]. / Néphrectomie chez le donneur vivant par voie laparoscopique robot-assistée: évaluation préopératoire et résultats à partir de 100 cas.

AIM: To assess short term morbidity and renal function after robotic laparoscopic living donor nephrectomy. PATIENTS AND METHODS: We performed a retrospective analysis of 100 consecutives patients undergoing a robotic laparoscopic living donors nephrectomy. We analyzed isotopic measure of the renal function before and 4 months after surgery, the side, the number of arteries, the blood loss, the operative time and warm ischemia time. In the outcomes, we collected the complications, the length of stay, and for the receiver, the renal function recovery time, dialysis, survival and renal function at one year. RESULTS: Left kidney nephrectomy was performed in 85 patients and we observed 25 multiples renal arteries. Mean estimated blood loss was 0,8 g/dL. Mean operative time and warm ischemia time were respectively 174 ± 30 and 4.8 ± 1.7 minutes. Seven complications occured, with 2 major (Clavien-Dindo System). Mean length of stay was 5.1 ± 1.9 days. Mean glomerular filtration decrease was 26% and remains stable at one year after surgery. Grafts had an immediate renal function recovery for 99%, and were all functional after one year, with mean MDRD clearance of 57 ± 14mL/min. CONCLUSION: Robotic procedure in laparoscopic living donor nephrectomy seems to guarantee low morbidity and the stability of the renal function decrease of 26%.

Guidelines and good clinical practice recommendations for contrast enhanced ultrasound (CEUS) in the liver--update 2012: a WFUMB-EFSUMB initiative in cooperation with representatives of AFSUMB, AIUM, ASUM, FLAUS and ICUS.

Initially, a set of guidelines for the use of ultrasound contrast agents was published in 2004 dealing only with liver applications. A second edition of the guidelines in 2008 reflected changes in the available contrast agents and updated the guidelines for the liver, as well as implementing some non-liver applications. Time has moved on, and the need for international guidelines on the use of CEUS in the liver has become apparent. The present document describes the third iteration of recommendations for the hepatic use of contrast enhanced ultrasound (CEUS) using contrast specific imaging techniques. This joint WFUMB-EFSUMB initiative has implicated experts from major leading ultrasound societies worldwide. These liver CEUS guidelines are simultaneously published in the official journals of both organizing federations (i.e., Ultrasound in Medicine and Biology for WFUMB and Ultraschall in der Medizin/European Journal of Ultrasound for EFSUMB). These guidelines and recommendations provide general advice on the use of all currently clinically available ultrasound contrast agents (UCA). They are intended to create standard protocols for the use and administration of UCA in liver applications on an international basis and improve the management of patients worldwide.

Motion compensated generalized reconstruction for free-breathing dynamic contrast-enhanced MRI.

The analysis of abdominal and thoracic dynamic contrast-enhanced MRI is often impaired by artifacts and misregistration caused by physiological motion. Breath-hold is too short to cover long acquisitions. A novel multipurpose reconstruction technique, entitled dynamic contrast-enhanced generalized reconstruction by inversion of coupled systems, is presented. It performs respiratory motion compensation in terms of both motion artefact correction and registration. It comprises motion modeling and contrast-change modeling. The method feeds on physiological signals and x-f space properties of dynamic series to invert a coupled system of linear equations. The unknowns solved for represent the parameters for a linear nonrigid motion model and the parameters for a linear contrast-change model based on B-splines. Performance is demonstrated on myocardial perfusion imaging, on six simulated data sets and six clinical exams. The main purpose consists in removing motion-induced errors from time-intensity curves, thus improving curve analysis and postprocessing in general. This method alleviates postprocessing difficulties in dynamic contrast-enhanced MRI and opens new possibilities for dynamic contrast-enhanced MRI analysis.

[Guidelines for contrast enhanced ultrasound (CEUS)--update 2008]. / Nouvelles recommandations pour l'utilisation des agents de contraste ultrasonores: mise à jour 2008.

These new recommendations are following the text published in 2004 by the group of experts of the EFSUMB that was augmented to reevaluate the indications of ultrasound contrast agents. Initially limited to focal liver lesions, new recommendations include the study of renal and pancreatic diseases, as well as vesico-ureteric reflux, blunt abdominal trauma and trans-cranial Doppler. Contrast-enhanced ultrasound improves the diagnosis of renal pseudo-tumors but does not allow characterization of solid focal masses. Its major contribution includes characterization of complex cystic masses, diagnosis of peripheral vascular disorders such as infarction and cortical necrosis, and radiofrequency ablation follow-up. It is also useful for the study of pancreatic masses visible at ultrasound in order to improve lesion visualization and characterization (adenocarcinoma and neuro-endocrine tumors), as well as for vascular staging.

[Impact of PACS implementation in a university center on radiology practice profile]. / Changements des pratiques radiologiques induites par l'implantation d'un réseau images en milieu hospitalo-universitaire.

PURPOSE: To determine the impact of a joint PACS implementation at a university medical center and cancer center on the radiology practice profile. Materials and methods. In 5 radiology sections, patients, selected based on identifiable acute or chronic diseases, underwent US, CT or MRI. Data were collected on datasheets from each provider with regards to clinical history, availability of prior examinations, description of patient management during the different phases of the examination, duration of examinations, and satisfaction. Data obtained prior to PACS implementation and 6-12 months and 30-36 months after implementation were compared. RESULTS: A total of 1098 datasheets were collected. Hard copy readings rapidly decreased. Comparison with prior examinations improved (+20.6% to 25.6%) as well as frequency of post-processing (+29%). The time required for image management was much more reduced for technologists (-75%) than for physicians (-23%). PACS implementation only temporarily improved the availability of radiology reports and the distribution of work between senior and junior radiologists. User satisfaction, initially high, progressively decreased due to saturation of the archival capabilities. CONCLUSION: PACS implementation in a large university center improves the efficiency of image acquisition but does not solve some of the inefficiencies of hospital organization.

[Real-time contrast-enhanced ultrasound in the evaluation of focal liver lesions: diagnostic efficacy and economical issues from a French multicentric study]. / Echographie de contraste temps réel dans la prise en charge diagnostique des lésions nodulaires hépatiques: évaluation des performances diagnostiques et de l'impact économique sur une étude multicentrique française.

The recent introduction of high-end ultrasound equipment combined with recent contrast agents provides marked improvements in the characterization of focal liver lesions as previously reported by monocentric studies. The aim of the present study was to evaluate the diagnostic performance of Contrast-Enhanced Ultrasonography (CEUS) using SonoVue as well as its medico-economic value for characterization of focal liver lesions. These nodules were not characterized on previous CT or conventional sonography. This prospective multicentric study conducted in 15 French centres found diagnostic performances similar to those reported for CT and MRI, with a concordance rate of 84.5%, sensitivity greater than 80% and specificity greater than 90% for all types of lesions. Higher acceptance was found for CEUS compared to other imaging modalities. Economical assessment based on examination reimbursment and contrast agent cost showed a lower cost for contrast ultrasound versus CT and MRI. This French multicentric study confirmed the high diagnostic value of CEUS for focal liver lesion characterization and demonstrated a lower economical impact compared to other imaging modalities such as CT and MRI.

[Cost-effectiveness evaluation of a digital radiography system]. / Evaluation médico-économique d'un système capteur-plan grand champ en radiopédiatrie.

PURPOSE: To evaluate the impact of a completely automated digital radiography (DR) unit in a pediatric radiology department on productivity. Materials and methods. Comparative evaluation of DR and computerized radiography (CR) units on 193 patients imaged in a pediatric radiology department. The time to complete each step of all examinations was recorded. Half of the exams were performed using CR and the other half was performed using DR. RESULTS: There was a 52% time gain for simple projection exams using DR and a 51% time gain for dual projection exams using DR (p<0.001). A workflow study performed a 9 month period showed that DR could absorb 84% of work previously performed on two conventional radiography units. CONCLUSION: DR is necessary for digital imaging departments to increase productivity, while providing added ergonomic comfort and flexibility. It is particularly well suited for pediatric imaging departments.

[Imaging of serious visceral forms of mucormycosis in five immunodepressed patients]. / Imagerie des formes viscérales graves de la mucormycose chez 5 patients immunodéprimés.

OBJECTIVES: Show the contribution of imaging to the diagnosis and follow-up of serious mucormycosis in immunodepressed patients. MATERIALS AND METHODS: Retrospective analysis of the 5-year radiological data in serious forms of mucormycosis occurring in patients with bone marrow allografts who are in refractory chronic graft-versus-host disease after bone marrow transplantation from 2002 to 2005. The positive diagnosis was bacteriologically and pathologically positive in all cases. RESULTS: This study involved three patients with isolated pulmonary involvement and two cases of disseminated mucormycosis. Areas of pulmonary condensations were found in all cases, one of whom had a low-attenuation zone and parenchymal nodules. The kidney, liver, and spleen lesions were clearly limited, hypoechogenic, hypodense, and homogenous with no peripheral contrast material uptake. There was thyroid involvement in the form of hypoechogenic nodules. Rapid growth of the lesions was observed on follow-up CT (n=3) and despite surgical treatment (n=2) and intensive medical management, all cases ended in death. CONCLUSION: Mucormycosis is an integral part of the differential diagnosis of infectious syndromes in immunodepressed patients during the period after bone marrow transplantation. Imaging can assist in the diagnosis but pathological confirmation remains indispensable.

CT imaging findings in patients with advanced hepatocellular carcinoma treated with sorafenib: Alternative response criteria (Choi, European Association for the Study of the Liver, and modified Response Evaluation Criteria in Solid Tumor (mRECIST)) versus RECIST 1.1.

PURPOSE: The first aim was to compare Response Evaluation Criteria in Solid Tumor (RECIST) 1.1, modified Response Evaluation Criteria in Solid Tumor (mRECIST), Choi and European Association for the Study of the Liver (EASL) evaluations to assess the response to sorafenib for hepatocellular carcinoma (HCC). The second aim was to describe the evolution of HCC and to identify whether some imaging features are predictive of the absence of response. MATERIALS AND METHODS: This retrospective study included 60 patients with advanced HCC treated with sorafenib. Patients must have undergone a scan prior to treatment to identify the number of lesions, size, enhancement and endoportal invasions, and repeat scans thereafter. Computed tomography (CT) scans were analyzed using RECIST 1.1, mRECIST, Choi and EASL criteria. Overall survival was analyzed. RESULTS: The median overall survival was 10.5 months. On the first CT reevaluation, the sorafenib response rates were 20%, 5%, 7% and 3% according to Choi, EASL, mRECIST and RECIST 1.1. The responders based on Choi exhibited significantly better overall survival compared with non-responders (20.4 months; hazard ratio (HR) 0.042, 95% confidence interval (CI): 0.186-0.94, p=0.035). A modification of imaging findings was observed in 48.3% of patients, and necrosis was present in 44.1% of patients. CONCLUSION: This study found a significant difference between Choi versus RECIST 1.1, mRECIST and EASL when evaluating the response to sorafenib in HCC patients.

Current practice and access to prostate MR imaging in France.

PURPOSE: To obtain an overview of the degree of discrepancy between current clinical practice of prostate magnetic resonance imaging (MRI) in France and recommendations. MATERIALS AND METHODS: A brief survey was sent to 1229 members of the French society of urology in order to identify their indications of prostate MRI and its impact on patient management. The urologists were asked to answer several questions regarding age, practice modality, prostate MRI examinations (technique, indication before first biopsy, second biopsy, cancer staging, active surveillance, recurrence, focal therapy) and quality of reports. RESULTS: A total of 445 responses were received (participation rate of 36%). The mean delay for obtaining an appointment for prostate MRI ranged between 15-30 days in 54%. Fifty-four percent of MRI reports contained a PIRADS score and 23% a Likert score. The indications of multiparametric-MRI were tumor detection/location prior to repeat biopsy (90%), cancer staging (85%), management of patients under active surveillance (85%), selection of candidates to focal therapy (63%), tumor detection/location in biopsy naïve patients (53%), detection of local recurrence after radical (51%). Only 119 urologists (28.6%) had access to image fusion (MRI and transrectal ultrasound) and 351 (85.4%) used cognitive fusion. Mostly, targeted biopsies are done by urologists alone (nearly 80%), a very few are done by radiologists (8%) or by the two of them in collaboration (12%). CONCLUSION: The majority of urologists consider that prostate MRI is essential for the management of patients with prostate cancer. Practices are ahead of recommendations particularly before the first biopsy and in active surveillance.

Successful surgical thrombectomy of renal allograft vein thrombosis in the early postoperative period.

We report the successful surgical treatment of two cases of renal vein thrombosis, each occurring early after kidney transplantation. Prompt intervention was a result of accurate diagnosis by color Doppler ultrasonography. Invasive radiological procedures were not useful. Although recent advances in thrombolytic therapy have created several alternatives to open surgery, the rationale for surgical exploration in these cases was to remove the thrombus quickly, to avoid the postoperative bleeding complications of thrombolytic therapy, and to correct any technical or anatomic problems.

Alcohol dependence among patients admitted to psychiatric emergency services.

We assessed the prevalence of alcohol dependence among patients examined in the psychiatric emergency service of a general hospital. We compared socio-demographic data and psychiatric status of patients with and without alcohol dependence. One-hundred and four consecutive patients received by the psychiatric emergency service of Bichat-Claude Bernard Hospital (Paris, France) were assessed. Diagnosis of alcohol dependence, acute alcohol intoxication, and antisocial personality was determined according to DSM-IV criteria. Other psychiatric disorders were identified using a structured psychiatric interview, the Mini International Neuropsychiatric Interview (MINI). Prevalency rate of alcohol dependence was 37.5% among patients examined by the psychiatric emergency service. Alcohol-dependent patients were more often men than women and more often unemployed than non-alcohol-dependent psychiatric emergencies. They presented more dysthymia, acute alcohol intoxication, and antisocial personality than non-alcoholic patients followed by the psychiatric emergency service. Attempted suicide was as frequent in alcohol-dependent patients (23%) as in other patients (29%). Alcohol-dependent patients consumed alcohol more often when alone, and their alcohol consumption began more frequently in the morning. Patients seen in a psychiatric emergency service must be identified as a population at risk for alcohol dependence (37.5%). Alcohol-dependent patients are more often men and have a higher rate of unemployment. They present significantly more often dysthymia and acute alcohol intoxication associated to alcohol dependence.

Relationship between blood pressure and renin, angiotensin II and atrial natriuretic factor after renal transplantation.

The objective of the study was to assess the evolution of renin, angiotensin II, atrial natriuretic factor (ANF) and blood pressure (BP) in the first trimester following renal transplantation in man Thirty-two recipients were investigated for 3 months post-transplantation. Twenty had a history of hypertension with moderate cardiac hypertrophy. Thirty-one retained their native kidneys. Five kidney donors had a history of mild hypertension. The recipients were perioperatively volume-expanded with 0.9% saline and diuresis was maintained for 48 h with furosemide and dopamine. The sodium intake was 25 mEq/24 hours. Prophylactic immunosuppressive therapy was antilymphocyteglobulins (25 cases), or anti-LFA1 (7 cases) and maintenance therapy was cyclosporine-prednisone (8 cases), or cyclosporine-prednisone-azathioprine (24 cases). Mean BP, serum creatinine, urinary sodium excretion (UNA) and hormonal (renin, angiotensin II and ANF) parameters were collected every other day for the first week after transplantation and then twice monthly. Twenty (62.5%) patients developed hypertension and hypertension was more frequent in patients with a delayed graft function, than in patients with immediate good graft function (10/20 vs. 4/12, p < 0.05%). Both hypertensive (group HBP) and normotensive (group NBP) patients had similar very low renin and angiotensin II plasma levels, after an initial early peak. Analysis of covariance with multiple regression analysis showed that in the HBP patients, BP was negatively correlated with UNA (p = 0.02) and positively with plasma ANF (p < 0.01). The normal BP patients also showed a correlation between BP and UNA, although it was limit of statistical significance (p = 0.05); there was no correlation between ANF and BP. We conclude that the RAS is rapidly depressed after renal transplantation and does not interfere with BP regulation. The hypertension in the early stage of post-transplantation varies inversely with the urinary sodium excretion. The defective sodium excretion, which dominates the effect of the low sodium diet, results in volume overload, increased ANF and volume-dependent hypertension.

Cardiac catheterization: dosimetry on patients.

Our study was made on 49 patients and we used capsules of lithium fluoride. The average fluoroscopy time was 32 min. and the average cinema film length was 76.5 metres. The relationship between the entry dose, the fluoroscopy time and the length of cinema film allowed us to calculate a fluoroscopy equivalent time (F.E.T) for each patient which was of 51 min. (32 min. + 76/4) as radiation dose of one minute fluoroscopy equal radiation dose of 4 metres of cinema film. The average heart dose was 0.70 X 10(-3) X FET (GY) or 70 mr/min. There was an absence of relation of the exit dosage to the diameter of the patient and a proportionality of the heart dose to the exit dose. Furthermore the maximum eye dose recorded was 200 mrads and the maximum gonadal dose was 350 mrads.

Imaging of angiomyolipomas.

In this article we review renal angiomyolipomas (AMLs) from cases in the world literature and 60 cases from our own institution. We also analyze the role and the place of the various imaging techniques in the detection and diagnosis of AMLs. Discussion is focused on the natural history of this benign neoplasm as an isolated form or as a part of the tuberous sclerosis (TS) complex or as part of a third less certain group of multiple AML without stigmata of TS. We also consider the growth patterns and hemorrhagic risks of AML to help define an approach to the current management of this lesion.

Malignant change in an intradiploic epidermoid cyst.

We describe a unique case of an intra-diploic epidermoid cyst of the parietal and occipital right bone in a 43 year-old man. The tumor remained quiescent for 12 years and then spontaneously showed malignant changes with intra-cerebral involvement. Fatal outcome occurred one year after surgery, radiation therapy and chemotherapy because of a recurrence. Malignant transformation of the epithelium in epidermoid cyst is very rare. Our case is the first one where this transformation occurred spontaneously without previous surgery.