Metabolic tumor volume predicts outcome in patients with advanced stage follicular lymphoma from the RELEVANCE trial.

BACKGROUND: We investigated the prognostic value of baseline positron emission tomography (PET) parameters for patients with treatment-naïve follicular lymphoma (FL) in the phase III RELEVANCE trial, comparing the immunomodulatory combination of lenalidomide and rituximab (R2) versus R-chemotherapy (R-chemo), with both regimens followed by R maintenance therapy. PATIENTS AND METHODS: Baseline characteristics of the entire PET-evaluable population (n = 406/1032) were well balanced between treatment arms. The maximal standard uptake value (SUVmax) and the standardized maximal distance between tow lesions (SDmax) were extracted, the standardized distance between two lesions the furthest apart, were extracted. The total metabolic tumor volume (TMTV) was computed using the 41% SUVmax method. RESULTS: With a median follow-up of 6.5 years, the 6-year progression-free survival (PFS) was 57.8%, the median TMTV was 284 cm3, SUVmax was 11.3 and SDmax was 0.32 m-1, with no significant difference between arms. High TMTV (>510 cm3) and FLIPI were associated with an inferior PFS (P = 0.013 and P = 0.006, respectively), whereas SUVmax and SDmax were not (P = 0.08 and P = 0.12, respectively). In multivariable analysis, follicular lymphoma international prognostic index (FLIPI) and TMTV remained significantly associated with PFS (P = 0.0119 and P = 0.0379, respectively). These two adverse factors combined stratified the overall population into three risk groups: patients with no risk factors (40%), with one factor (44%), or with both (16%), with a 6-year PFS of 67.7%, 54.5%, and 41.0%, respectively. No significant interaction between treatment arms and TMTV or FLIPI (P = 0.31 or P = 0.59, respectively) was observed. The high-risk group (high TMTV and FLIPI 3-5) had a similar PFS in both arms (P = 0.45) with a median PFS of 68.4% in the R-chemo arm versus 71.4% in the R2 arm. CONCLUSIONS: Baseline TMTV is predictive of PFS, independently of FLIPI, in patients with advanced FL even in the context of antibody maintenance.

FDG-PET-driven consolidation strategy in diffuse large B-cell lymphoma: final results of a randomized phase 2 study.

Dose-dense induction and up-front consolidation with autologous stem cell transplantation (ASCT) remain controversial issues when treating patients with high-risk diffuse large B-cell lymphoma. GELA designed a randomized phase 2 trial evaluating the efficacy of either rituximab, doxorubicin, cyclophosphamide, vindesine, bleomycin, prednisone (R-ACVBP) or rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone (R-CHOP14) induction and a positron emission tomography (PET)-driven ASCT or standard immunochemotherapy (SIC) consolidation in age-adjusted international prognosis index 2 (aaIPI2)-aaIPI3 patients. PET was performed at baseline, after 2 (PET2) and 4 (PET4) induction cycles, and centrally assessed using international harmonization project (IHP) criteria. PET2-/PET4- patients were assigned SIC, PET2+/PET4- patients were assigned ASCT, and PET4+ patients were treated with the investigator's choice. The primary end-point was the 2007 international working group complete response (CR) rate after induction. Change in maximum standard uptake value (ΔSUVmax) after PET assessment was explored. Two hundred eleven patients were randomly assigned to R-ACVBP (n = 109) or R-CHOP14 (n = 102). PET4-/CR rates were 53%/47% with R-ACVBP and 41%/39% with R-CHOP14 (CR 95% confidence interval [CI], 38%-67% and 28%-54%, respectively; P = .076). Consolidation in the R-ACVBP and R-CHOP14 groups was SIC in 26% and 23% of patients and ASCT in 28% and 18% of patients, respectively. PET4 positivity was higher with R-CHOP14 vs R-ACVBP (54% vs 41%; P = .08), leading to more salvage therapy (37% vs 26%; P = .07) and lower event-free survival (EFS; 4-year EFS, 31% vs 43%; P < .01), but progression-free survival (PFS) and overall survival (OS) were similar in both groups. PET2-/PET4- and PET2+/PET4- patients had similar outcomes. Using ΔSUVmax, 79% of the patients were PET2-/PET4- ΔSUVmaxPET0-4 >70% was associated with better outcome (4-year PFS, 84% vs 35%; 4-year OS, 91% vs 57%; P < .0001), whatever the consolidation. Superiority of R-ACVBP over R-CHOP14 was not established, as IHP criteria did not properly reflect disease control. ΔSUVmax may help better select patients needing an alternative to SIC, including ASCT.

BCL2 expression but not MYC and BCL2 coexpression predicts survival in elderly patients with diffuse large B-cell lymphoma independently of cell of origin in the phase 3 LNH03-6B trial.

BACKGROUND: Our aim was to evaluate whether the cell of origin (COO) as defined by the Hans algorithm and MYC/BCL2 coexpression, which are the two main biological risk factors in elderly patients treated with rituximab, cyclophosphamide, doxorubicin hydrochloride, vincristine, and prednisolone (R-CHOP), maintain their prognostic value in a large prospective clinical trial. PATIENTS AND METHODS: We evaluated 285 paraffin-embedded samples from patients (60-80 years of age) enrolled in the Lymphoma Study Association trial LNH03-6B who were treated with R-CHOP. We correlated the COO defined by the transcriptome according to the Wright algorithm with that defined by the Hans algorithm in a subset of 62 tumors with available frozen tissue samples. RESULTS: The non-germinal center B-cell-like phenotype according to the Hans algorithm and BCL2 expression (but not MYC and BCL2 coexpression) predicted worse progression-free survival [hazard ratio (HR)=1.78, P = 0.003 and HR = 1.79, P = 0.003, respectively] and overall survival (HR = 1.85, P = 0.005 and HR = 1.67, P = 0.02, respectively) independently of the International Prognostic Index. The correlation between the Hans algorithm and the Wright algorithm was 91%, with an almost perfect concordance according to a kappa test (0.81). CONCLUSIONS: Our results suggest that immunohistochemically defined COO remains a useful tool for predicting prognosis in diffuse large B-cell lymphoma when performed under optimized standardized conditions and that BCL2 expression may help to identify elderly patients at risk for relapse and who could potentially respond to anti-BCL2 targeted agents. In this prospective phase III trial, the coexpression of MYC and BCL2 does not appear to predict worse survival. CLINICAL TRIAL NUMBER: NCT00144755.

Popliteal Artery Entrapment Syndrome in Children: Experience With Four Cases of Acute Ischaemia and Review of the Literature.

OBJECTIVE: Popliteal artery entrapment syndrome (PAES) is an uncommon anatomical anomaly, frequently described in adults. The most common symptom is claudication. Acute limb ischaemia (ALI) in children is rare, but it may evolve and lead to limb loss or lifelong complications. Clinical and surgical experience of PAES in children is reported. Data from the literature are analysed in order to assess the severity of this disease and to identify the factors characterising the diagnosis and the outcome of treatment in paediatric patients. METHODS: Four children (aged 7-16 years) were referred with ALI due to PAES. Among the 439 articles reporting cases of PAES, 55 patients under 18 years of age were the focus. The PAES cases were classified according to the Love and Whelan classification modified by Rich. RESULTS: Data from 79 children (106 limbs, 27 bilateral PAES) were collected and analysed. Type I PAES was present in 41 (39%), Type II in 23 (22%), Type III in 24 (23%), Type IV in 12 (11%), and Type V in two (2%) limbs. A functional PAES was present in one patient bilaterally. In two cases, the type of PAES was not reported. Claudication occurred in 68 cases (64%), and ALI in 19 (18%). In 60 cases (57%), revascularisation with or without myotomy was required; myotomy alone was performed in 41 cases (39%). CONCLUSIONS: Symptomatic PAES in children should be considered a severe condition requiring urgent investigation in order to avoid any delays in the treatment. Early diagnosis and treatment are essential to prevent serious complications. The long-term outcomes of surgical treatment with the correction of the anatomical anomaly and vascular reconstruction are satisfactory with a low complication rate.

Amplatzer Plug to Occlude the Internal Iliac Artery During Endovascular Aortic Aneurysm Repair: A Large Multicenter Study.

OBJECTIVE: During endovascular repair of abdominal aortic aneurysms (EVAR), in the absence of a distal iliac landing zone, the Amplatzer plug is increasingly being used to replace other internal iliac artery (IIA) embolization techniques. This study aimed at assessing the technical success, complication occurrence, and durability of the Amplatzer plug for IIA embolization. METHOD: From January 1, 2007 to December 31, 2013, all consecutive patients who underwent internal iliac embolization with an Amplatzer plug during EVAR were included in the study. There were 169 patients, (160 men, 9 women, mean 75 ± 9 years), treated by unilateral (158 cases, 93%) or bilateral (11 cases, 7%) embolization of the IIA, performed either separately prior to (65 cases, 38.5%) or during EVAR (104 cases, 61.5%). Follow up CT scan and/or US scan were performed 1 month after treatment and yearly thereafter. The inclusions were done retrospectively but the series was continuous and consecutive. Data were collected and analyzed using acquisition REDCap software. RESULTS: The technical success rate was 97.6%. Failures were device migration (n = 1), navigation failure (n = 2), and release outside the target zone (n = 1). On average, 1.43 plugs were required to achieve the embolization. The average amount of contrast agent for the embolization procedure was 111 ± 51 mL and the radiation dose was 127,777 ± 89,528 mGy/cm(2). The total fluoroscopy time was 854 ± 538 seconds. No re-canalization of the IIA trunk was observed during follow up. Complications were buttock claudication (n = 41, 24.3%), which resolved in 24 cases (58.5%, 24/41) at the first follow up, and intestinal ischemia requiring limited bowel resection in two cases. CONCLUSION: This multicenter study is the largest published to date. It demonstrates the efficacy and reliability of the Amplatzer plug to embolize the IIA during EVAR, with few side effects.

Locally advanced pancreatic duct adenocarcinoma: pancreatectomy with planned arterial resection based on axial arterial encasement.

Pancreatectomy with arterial resection for locally advanced pancreatic duct adenocarcinoma (PDA) is associated with high morbidity and is thus considered as a contraindication. The aim of our study was to report our experience of pancreatectomy with planned arterial resection for locally advanced PDA based on specific selection criteria. MATERIAL AND METHODS: All patients receiving pancreatectomy for PDA between October 2008 and July 2014 were reviewed. The patients were classified into group 1, pancreatectomy without vascular resection (66 patients); group 2, pancreatectomy with isolated venous resection (31 patients), and group 3, pancreatectomy with arterial resection for locally advanced PDA (14 patients). The primary selection criteria for arterial resection was the possibility of achieving a complete resection based on the extent of axial encasement, the absence of tumor invasion at the origin of celiac trunk (CT) and superior mesenteric artery (SMA), and a free distal arterial segment allowing reconstruction. Patient outcomes and survival were analyzed. RESULTS: Six SMA, two CT, four common hepatic artery, and two replaced right hepatic artery resections were undertaken. The preferred arterial reconstruction was splenic artery transposition. Group 3 had a higher preoperative weight loss, a longer operative time, and a higher incidence of intraoperative blood transfusion. Ninety-day mortality occurred in three patients in groups 1 and 2. There were no statistically significant differences in the incidence, grade, and type of complications in the three groups. Postoperative pancreatic fistula and postpancreatectomy hemorrhage were also comparable. In group 3, none had arterial wall invasion and nine patients had recurrence (seven metastatic and two loco-regional). Survival and disease-free survival were comparable between groups. CONCLUSION: Planned arterial resection for PDA can be performed safely with a good outcome in highly selected patients. Key elements for defining the resectability is based on the extent of the axial arterial encasement with two criteria: the origin of the CT and SMA are free from tumor invasion and the possibility of distal reconstruction.

Treatment of older patients with mantle-cell lymphoma.

BACKGROUND: The long-term prognosis for older patients with mantle-cell lymphoma is poor. Chemoimmunotherapy results in low rates of complete remission, and most patients have a relapse. We investigated whether a fludarabine-containing induction regimen improved the complete-remission rate and whether maintenance therapy with rituximab prolonged remission. METHODS: We randomly assigned patients 60 years of age or older with mantle-cell lymphoma, stage II to IV, who were not eligible for high-dose therapy to six cycles of rituximab, fludarabine, and cyclophosphamide (R-FC) every 28 days or to eight cycles of rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) every 21 days. Patients who had a response underwent a second randomization to maintenance therapy with rituximab or interferon alfa, each given until progression. RESULTS: Of the 560 patients enrolled, 532 were included in the intention-to-treat analysis for response, and 485 in the primary analysis for response. The median age was 70 years. Although complete-remission rates were similar with R-FC and R-CHOP (40% and 34%, respectively; P=0.10), progressive disease was more frequent with R-FC (14%, vs. 5% with R-CHOP). Overall survival was significantly shorter with R-FC than with R-CHOP (4-year survival rate, 47% vs. 62%; P=0.005), and more patients in the R-FC group died during the first remission (10% vs. 4%). Hematologic toxic effects occurred more frequently in the R-FC group than in the R-CHOP group, but the frequency of grade 3 or 4 infections was balanced (17% and 14%, respectively). In 274 of the 316 patients who were randomly assigned to maintenance therapy, rituximab reduced the risk of progression or death by 45% (in remission after 4 years, 58%, vs. 29% with interferon alfa; hazard ratio for progression or death, 0.55; 95% confidence interval, 0.36 to 0.87; P=0.01). Among patients who had a response to R-CHOP, maintenance therapy with rituximab significantly improved overall survival (4-year survival rate, 87%, vs. 63% with interferon alfa; P=0.005). CONCLUSIONS: R-CHOP induction followed by maintenance therapy with rituximab is effective for older patients with mantle-cell lymphoma. (Funded by the European Commission and others; ClinicalTrials.gov number, NCT00209209.).

Editor's Choice - ECAR (Endovasculaire ou Chirurgie dans les Anévrysmes aorto-iliaques Rompus): A French Randomized Controlled Trial of Endovascular Versus Open Surgical Repair of Ruptured Aorto-iliac Aneurysms.

OBJECTIVES/BACKGROUND: ECAR (Endovasculaire ou Chirurgie dans les Anévrysmes aorto-iliaques Rompus) is a prospective multicentre randomized controlled trial including consecutive patients with ruptured aorto-iliac aneurysms (rAIA) eligible for treatment by either endovascular (EVAR) or open surgical repair (OSR). Inclusion criteria were hemodynamic stability and computed tomography scan demonstrating aorto-iliac rupture. METHODS: Randomization was done by week, synchronously in all centers. The primary end point was 30 day mortality. Secondary end points were post-operative morbidity, length of stay in the intensive care unit (ICU), amount of blood transfused (units) and 6 month mortality. RESULTS: From January 2008 to January 2013, 107 patients (97 men, 10 women; median age 74.4 years) were enrolled in 14 centers: 56 (52.3%) in the EVAR group and 51 (47.7%) in the OSR group. The groups were similar in terms of age, sex, consciousness, systolic blood pressure, Hardman index, IGSII score, type of rupture, use of endoclamping balloon, and levels of troponin, creatinine, and hemoglobin. Delay to treatment was higher in the EVAR group (2.9 vs. 1.3 hours; p < .005). Mortality at 30 days and 1 year were not different between the groups (18% in the EVAR group vs. 24% in the OSR group at 30 days, and 30% vs. 35%, respectively, at 1 year). Total respiratory support time was lower in the EVAR group than in the OSR group (59.3 hours vs. 180.3 hours; p = .007), as were pulmonary complications (15.4% vs. 41.5%, respectively; p = .050), total blood transfusion (6.8 vs. 10.9, respectively; p = .020), and duration of ICU stay (7 days vs. 11.9 days, respectively; p = .010). CONCLUSION: In this study, EVAR was found to be equal to OSR in terms of 30 day and 1 year mortality. However, EVAR was associated with less severe complications and less consumption of hospital resources than OSR.

Ultrasound-guided intermediate cervical plexus block for carotid endarterectomy using a new anterior approach: a two-centre prospective observational study.

The aim of this prospective, double-centre, observational study performed in 116 patients was to describe a new anterior approach of ultrasound-guided intermediate cervical plexus block for carotid endarterectomy. The median (IQR [range]) volume of ropivacaine 0.5% administered was 30 (25-30 [20-45]) ml. Supplemental local anaesthesia (infiltration and topical) was needed in 66 (57%) patients. Overall, 41 (35%) patients needed additional sedation (18 midazolam; 23 remifentanil). There was no intra-operative complication or systemic toxicity of ropivacaine. One regional anaesthesia procedure was converted to general anaesthesia because of patient agitation. Adverse effects were of short duration and did not affect surgery. Satisfaction scores were high for 92 (79%) patients (63 satisfied; 29 very satisfied) and 104 (90%) surgeons (51 satisfied; 53 very satisfied). This study shows that the ultrasound-guided intermediate cervical plexus block using an anterior approach is feasible and provides similar results to other regional techniques during carotid endarterectomy.

Editor's choice--hybrid treatment of thoracic, thoracoabdominal, and abdominal aortic aneurysms: a multicenter retrospective study.

OBJECTIVES: The aim of this study was to assess the results of hybrid techniques for the treatment of thoracic, thoracoabdominal, and abdominal aortic aneurysms based on multicenter results and the various series regarding hybrid procedures reported in the literature. METHODS: The results of 76 hybrid procedures performed in 19 French university hospital centers between November 2001 and October 2011 were collected. There were 50 men and 26 women, mean age 68.2 (35-86) years. All patients were considered at high risk (ASA≥3) for conventional surgery. Aneurysms involved the thoracic, abdominal, and thoracoabdominal aorta in five, 14, and 57 cases respectively. There were 11 emergent repairs. The revascularization of four visceral arteries was performed in 38 cases. Between one and three visceral arteries were revascularized in the other cases. Visceral artery debranching and stent graft deployment were performed in a one-stage procedure in 53 cases and in a two-stage procedure in 23 cases. RESULTS: There were 26 (34.2%) postoperative deaths. Nine of the survivors developed paraplegia, of which one resolved completely. Bowel ischemia occurred in 13 cases (17.1%), and one patient was treated by a superior mesenteric artery bypass. Four patients required long-term hemodialysis. Postoperative computed tomography scan showed a type II endoleak in two patients. CONCLUSIONS: Morbidity and mortality in this study were greater than previously reported. Candidates for hybrid aortic repair should be carefully selected.

Lymphoma occurring in patients over 90 years of age: characteristics, outcomes, and prognostic factors. A retrospective analysis of 234 cases from the LYSA.

BACKGROUND: Lymphoma occurring in patients aged 90 or older is not uncommon, and its incidence is expected to increase over time. Management of these patients is difficult given their underlying fragility and the lack of information regarding this population. PATIENTS AND METHODS: We retrospectively analyzed 234 patients diagnosed with lymphoma at the age of 90 years or older (90+) between 1990 and 2012 to describe their characteristics, management, outcomes and prognostic factors. RESULTS: The median age was 92 years; 88% were B-cell lymphomas consisting mainly in diffuse large B-cell lymphoma. The median overall survival (OS) was 7.2 months (range, 0-92 months) for the 227 patients with non-Hodgkin Lymphoma (NHL), with a significant difference between aggressive and indolent NHL (5.2 months versus 19.4 months, respectively). We further analyzed 166 NHL patients for whom detailed characteristics were available. Among these patients, 63.5% received a treatment, either local (7.5%) or systemic (56%). Lymphoma was reported as the main cause of death (40%). Treatment administration was associated with improved OS in patients with aggressive (P < 0.001) but not indolent NHL (P = 0.96). In patients with aggressive NHL, hypoalbuminemia appeared as a strong and independent negative prognostic factor. CONCLUSIONS: The median OS is short in 90+ patients diagnosed with lymphoma but some patients experience prolonged survival. Lymphoma represents the main cause of death in these patients. Treatment may improve survival of selected patients with aggressive but not indolent NHL. Management of these patients may be guided by prognostic factors identified in this study, notably serum albumin.

Early and late results of contemporary management of 37 secondary aortoenteric fistulae.

PURPOSE: Evaluate the results of the two modalities used for the treatment of Secondary Aorto-Enteric Fistula (SAEF): In situ Reconstruction (ISR) and Extra-Anatomic Reconstruction (EAR). The primary endpoints of this study were early standard 30-day mortality and reinfection (RI). Secondary endpoints were perioperative morbidity, late mortality, primary graft patency, and major amputation rates. MATERIAL & METHOD: Diagnosis of SAEF was based on clinical examination and the results of pre-operative duplex or CT scans. Surgical management was performed according to local protocols at the participating institutions: - Elective surgery: ISR or staged EAR. - Emergency surgery: aortic clamping followed by ISR or EAR. - Selected high-risk patients: endovascular repair. Statistical analyses were performed using the actuarial method. Univariate analysis was used for analysis of categorical variables, and multivariate analysis was performed with a Cox proportional hazard regression. RESULTS: A total of 37 patients were included in this retrospective multicentre study. Mean follow-up was 41 months. The majority of the patients (20, 54%) presented acutely. EAR was performed in 9 patients (24%), ISR in 25 (68%), and 3 patients underwent endovascular repair. Bacteriological cultures were negative in 3 patients (9%). The most frequent organisms identified were Candida species and Escherichia coli. The 30-day mortality was 43% (16 patients). Patient age (>75 years) was the sole predictive factor associated with operative mortality (p = 0.02); pre-operative shock was not statistically significant (p = 0.08). There were 2 graft thromboses and 1 femoral amputation. Primary graft patency was respectively 89% at 1 year and 86% at 5 years; limb salvage rates were 100% at 1 and 5 years and 86% at 6 years, with no difference between ISR and EAR. RI occurred after 9.3 ± 13 months in 8 of 17 surviving patients and was fatal in all cases. For all surviving patients, the RI rate at 1 and 2 years was 24% and 41% respectively. There was no significant difference in the rate of RI after ISR or EAR. CONCLUSION: EAR does not appear to be superior to ISR. The risk of RI increased with the length of follow-up, irrespective of the treatment modality. Life-long surveillance is mandatory. Our results with endovascular sealing of SAEF should be considered a bridge to open repair.

Extra-anatomical hepatic artery reconstruction following post-embolization iatrogenic dissection and arterial anastomotic rupture in two liver transplant recipients.

When hepatic artery reconstruction is required during hepatic transplantation, this is generally performed with donor vessels. We describe two cases requiring a prosthesis. The first case was a 58-year-old man transplanted for cirrhosis complicated by hepatocellular carcinoma. During transplantation, dissection of the celiac trunk occurred due to arterial embolization and the use of the patient's vessels was impossible. An extra-anatomical bypass between the infra-renal aorta and the donor hepatic artery was performed via the interposition of a graft tube. The second case was a 52-year-old man transplanted for cirrhosis complicated by hepatocellular carcinoma. On day 16, a ruptured anastomosis was suspected and the patient underwent emergency revision laparotomy. Arterial revascularisation was performed with an aortohepatic bypass using a synthetic GoreTex((R)) graft. Patient follow-up was uneventful.

Arterial endofibrosis in endurance athletes: Prospective comparison of the diagnostic accuracy of intra-arterial digital subtraction angiography and computed tomography angiography.

PURPOSE: To prospectively compare the diagnostic capabilities of computed tomography angiography (CTA) to those of digital subtraction angiography (DSA) in endurance athletes with suspicion of arterial endofibrosis. MATERIALS AND METHODS: Forty-five athletes (39 men, 6 women; median age: 30 years, interquartile range: 23-42 years) prospectively underwent DSA and CTA without (n=5) or with (n=40) electrocardiogram gating. DSA was interpreted by a single expert (experience of 15 years). CTA was independently interpreted by three other readers (experience of 5-8 years). Readers assessed the presence and degree of stenoses on iliac and femoral arteries and the overall diagnosis (negative, uncertain, positive) of endofibrosis at the limb level. Sensitivities and specificities of DSA and CTA were estimated at the limb level using histological findings and long-term follow-up as reference, and compared using the McNemar test. RESULTS: For diagnosing and quantifying stenoses, concordance between DSA and CTA was moderate-to-good for common and external iliac arteries, moderate for lateral circumflex arteries and poor-to-moderate for the other branches of the deep femoral artery. It was good for all readers for the overall diagnosis of endofibrosis. After long-term follow-up (median, 95 months; interquartile range: 7-109 months), DSA sensitivity and specificity were respectively 88.6% (39/44; 95% confidence interval [CI]: 76-95%) and 75% (24/32; 95% CI: 57.9-86.7%); CTA sensitivity and specificity were respectively 88.6% (39/44; 95% CI: 76-95%; P>0.99) and 84.4% (27/32; 95% CI: 68.2-93.1%; P=0.51), 86.3% (38/44; 95% CI: 73.3-93.6%; P>0.99) and 75% (24/32; 95% CI: 57.9-86.7%; P>0.99), and 84.1% (37/44; 95% CI: 70.6-92.1%; P=0.68) and 75% (24/32; 95% CI: 57.9-86.7%; P>0.99) for the three readers. CONCLUSION: CTA shows performances similar to those of DSA in predicting the long-term diagnosis of endofibrosis in endurance athletes with suggestive symptoms.

Conversion to open repair after endovascular aneurysm repair: causes and results. A French multicentric study.

OBJECTIVE: To evaluate the causes and results of conversion to open repair after aortic aneurysm endovascular treatment (EVAR). DESIGN: Retrospective study of open conversion after EVAR was performed in eight French academic centres. Primary conversion (PC) within 30 days after EVAR and secondary conversions (SC) were analysed separately. RESULT: Between 1997 and 2007, open conversions were performed in 34 patients (most often in high-risk patients): 14 PC and 20 SC. Two main causes of PC were unfavourable iliac artery anatomy and renal artery coverage. In hospital mortality was 21%. SC occurred at a median of 44 months after primary EVAR. Nine were urgent cases for rupture or infection and 11 elective for aneurysm growth, infection or thrombosis. Early mortality was similar after emergent or elective SC (25%). CONCLUSION: Open conversion, and, in particular, PC and urgent SC, was associated with a poor outcome. According to the literature, mortality after elective SC is low but remains high in high-risk patients.

Two Rare Complications in One Patient: Acquired von Willebrand Syndrome Associated with Intracranial Plasmacytoma.

Here, we describe a rare case of acquired von Willebrand syndrome (VWS) associated with intracranial plasmacytoma. The literature includes reports of a few cases of plasmacytoma with central nervous involvement, but none of them with acquired VWS. Diagnosis was made based on a stereotaxic intracerebral biopsy. During this biopsy, a ventriculoperitoneal shunt was established, which was complicated with abnormal bleeding. Subsequent hemostasis assessment related to hemopathy revealed acquired von Willebrand disease. The patient received induction therapy with bortezomib, thalidomide, and dexamethasone (VTD), followed by high-dose melphalan chemotherapy and autologous stem cell transplantation, and then VTD consolidation, and finally maintenance with lenalidomide. Our patient currently remains in very good partial response without neurological symptoms after 4 months of maintenance. The patient is free of progression 14 months after their original presentation.

Idelalisib in a patient with refractory Waldenström's macroglobulinemia complicated by anuric renal failure: a case report.

BACKGROUND: Waldenström's macroglobulinemia is a rare B-cell lymphoma. The gold standard treatment for Waldenström's macroglobulinemia is an anti-CD20 antibody (rituximab) in combination with alkylating agents and dexamethasone. Treatment targeting the B-cell receptor such as ibrutinib (but not idelalisib) is currently approved for treatment of patients with relapsed or refractory Waldenström's macroglobulinemia. CASE PRESENTATION: We report a case of a 71-year-old white French man with Waldenström's macroglobulinemia who presented with acute renal failure and hyperviscosity syndrome. His Waldenström's macroglobulinemia was refractory to first-line treatment with rituximab, cyclophosphamide, and dexamethasone. Because of his hemorrhagic syndrome and medical history of recent myocardial infarction, we decided to treat him with idelalisib 150 mg twice daily instead of ibrutinib. We observed a very quick improvement in the patient's clinical status without need for dose adjustment. CONCLUSION: Our patient's case provides the first evidence, to the best of our knowledge, that idelalisib may be an efficient treatment option for patients with Waldenström's macroglobulinemia complicated by anuric renal failure and in whom ibrutinib is contraindicated.

Urgent endovascular covered-stent treatment of internal carotid artery injury caused by a gunshot.

Penetrating non-lethal injuries to the distal extra-cranial internal carotid artery are often a surgical challenge, because of the difficulty of direct exposure and repair of the internal carotid artery at the skull base. We describe a case of a successful emergency treatment, with an endovascular procedure using a PTFE covered-stent, of an internal carotid artery haemorrhagic pseudoaneurysm following penetrating trauma to the neck by single gunshot.

[Evaluation of a telemedicine system for the transmission of morpho/immunological data at the inclusion of patients in a therapeutic trial (Goelams LLC 98)]. / Validation du diagnostic morpho-immunologique par télétransmission en vue de l'inclusion dans un protocole thérapeutique (Goelams LLC 98).

The performances of the images digitalization and teletransmission systems make them more and more used. Applied to cellular haematology, they contribute to confrontations of diagnosis mostly within the framework of therapeutic trials. We present one of the first approaches of the use of telehematology for the inclusion of patients in the Goelams Chronic Lymphocytic Leukaemia 98 trial. The advantages were the constitution of a protected data bank, conveniently consultable; expertise on identical documents; facility of the exchanges between experts. We were able to set new standards of images sampling for CLL, solve the semantic divergences, to point out the inter-observer variability for the morphology. The limiting factors were the personal investment of the experts, but mainly the implication of first line morphologists which should benefit from adequate tools to apprehend this system of second reading like a quality control.

Long-term results of the R-CHOP study in the treatment of elderly patients with diffuse large B-cell lymphoma: a study by the Groupe d'Etude des Lymphomes de l'Adulte.

PURPOSE: To analyze the long-term outcome of patients included in the Lymphome Non Hodgkinien study 98-5 (LNH98-5) comparing cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) to rituximab plus CHOP (R-CHOP) in elderly patients with diffuse large B-cell lymphoma. PATIENTS AND METHODS: LNH98-5 was a randomized study that included 399 previously untreated patients, age 60 to 80 years, with diffuse large B-cell lymphoma. Patients received eight cycles of classical CHOP (cyclophosphamide 750 mg/m(2), doxorubicin 50 mg/m(2), vincristine 1.4 mg/m(2), and prednisone 40 mg/m(2) for 5 days) every 3 weeks. In R-CHOP, rituximab 375 mg/m(2) was administered the same day as CHOP. Survivals were analyzed using the intent-to-treat principle. RESULTS: Median follow-up is 5 years at present. Event-free survival, progression-free survival, disease-free survival, and overall survival remain statistically significant in favor of the combination of R-CHOP (P = .00002, P < .00001, P < .00031, and P < .0073, respectively, in the log-rank test). Patients with low-risk or high-risk lymphoma according to the age-adjusted International Prognostic Index have longer survivals if treated with the combination. No long-term toxicity appeared to be associated with the R-CHOP combination. CONCLUSION: Using the combination of R-CHOP leads to significant improvement of the outcome of elderly patients with diffuse large B-cell lymphoma, with significant survival benefit maintained during a 5-year follow-up. This combination should become the standard for treating these patients.