Immune checkpoint inhibitor treatment of a first cancer is associated with a decreased incidence of second primary cancer.

BACKGROUND: Second primary cancers (SPCs) are diagnosed in over 5% of patients after a first primary cancer (FPC). We explore here the impact of immune checkpoint inhibitors (ICIs) given for an FPC on the risk of SPC in different age groups, cancer types and treatments. PATIENTS AND METHODS: The files of the 46 829 patients diagnosed with an FPC in the Centre Léon Bérard from 2013 to 2018 were analyzed. Structured data were extracted and electronic patient records were screened using a natural language processing tool, with validation using manual screening of 2818 files of patients. Univariate and multivariate analyses of the incidence of SPC according to patient characteristics and treatment were conducted. RESULTS: Among the 46 829 patients, 1830 (3.9%) had a diagnosis of SPC with a median interval of 11.1 months (range 0-78 months); 18 128 (38.7%) received cytotoxic chemotherapy (CC) and 1163 (2.5%) received ICIs for the treatment of the FPC in this period. SPCs were observed in 7/1163 (0.6%) patients who had received ICIs for their FPC versus 437/16 997 (2.6%) patients receiving CC and no ICIs for the FPC versus 1386/28 669 (4.8%) for patients receiving neither CC nor ICIs for the FPC. This reduction was observed at all ages and for all histotypes analyzed. Treatment with ICIs and/or CC for the FPC are associated with a reduced risk of SPC in multivariate analysis. CONCLUSION: Immunotherapy with ICIs alone and in combination with CC was found to be associated with a reduced incidence of SPC for all ages and cancer types.

Thrombocytopenia due to hypersplenism in oncological disease: partial splenic embolization during palliative treatment.

Hypersplenism is excess activity of the spleen, resulting in peripheral pancytopenia that predominates in platelet cell lines. Pancytopenia can be limited by reducing the volume of the functional spleen. However, in patients in very poor general condition, a splenectomy may not be possible, due to the risks of surgery and postoperative infection. Another therapeutic alternative in these patients is to reduce the volume of the spleen by super selective percutaneous splenic embolization. We report three cases of peripheral thrombocytopenia due to hypersplenism with a platelet count between 60,000 and 80,000/mm(3), which made it impossible to continue or start a chemotherapy protocol in these patients. For these patients, super selective partial embolization of the splenic parenchyma, with uncharged microspheres (250 microns) quickly resulted in a platelet count above 150,000/mm(3) so that chemotherapy could be continued or initiated.

CT colonography: Why? When? How?

Although optical colonoscopy is still the gold standard for diseases of the colon, radiologic examination of the colon is now being performed by CT scan. Evaluation of the colon is enhanced by distension, which "de-folds" the intestinal wall, thus facilitating its examination for abnormalities of the mucosa, the wall as a whole, and the diameter of the bowel lumen. Water or gas (CO(2)) may be used for the distension, depending on the suspected lesions. The water enema method of colonography combines filling the bowel lumen with water and intravenous injection of a contrast medium. It is indicated when there is a clinical suspicion of colon cancer, or for initial discovery of liver metastases, and for staging of colon tumors. This technique, which requires little or no colon cleansing preparation, can be performed with no special equipment and has a short learning curve. The gas enema method of colonography, or virtual colonoscopy, is performed by distending the colon with CO(2), without any intravenous injection of contrast medium. Its purpose is to detect polyps as part of a screening for precancerous growths. This technique, which does require bowel cleansing preparation, uses a dedicated console for reading and requires specific training.

Small-bowel capsule endoscopy diagnoses early and advanced neoplasms in asymptomatic patients with Lynch syndrome.

BACKGROUND AND STUDY AIMS: Patients with Lynch syndrome are at increased risk of developing small-bowel adenocarcinoma, which usually has a bad prognosis and needs to be diagnosed early. Our aim was to evaluate the yield of capsule endoscopy and CT enteroclysis in this situation. PATIENTS AND METHODS: We performed a prospective, blinded, comparative study of capsule endoscopy and CT enteroclysis in five academic centers. Thirty-five consecutive asymptomatic patients with Lynch syndrome, all with one proven deleterious mutation, were included. A double reading was performed blind for both types of examination. RESULTS: Histologically confirmed small-bowel neoplasms were diagnosed in three patients (8.6 %): one adenocarcinoma (T3N0M0) and two adenomas with low-grade dysplasia. Capsule endoscopy identified all neoplasms. CT enteroclysis raised suspicion of one neoplasm (adenocarcinoma) but missed the two others. Concordance between the two capsule readings was high with a κ value of 0.78 (95 %CI 0.55 to 1.0), which was not the case for CT enteroclysis, where the κ value was 0.15 (95 %CI -0.27 to 0.58). CONCLUSION: Curable early or advanced neoplasms in asymptomatic patients with Lynch syndrome using capsule endoscopy can be detected with a better reproducibility than with CT enteroclysis. The clinical usefulness of systematic small-bowel screening in these patients should be confirmed through large prospective studies.

[Acute lower gastrointestinal bleeding: role of imaging]. / Hémorragies digestives basses aiguës: intérêt de l'imagerie.

Acute lower gastrointestinal bleeding is a frequent cause of hospital admission. Their management is complex and typically requires a multidisciplinary approach. The imaging techniques are variable. Because of the rapid image acquisition, excellent spatial resolution and multiplanar reformatting capabilities, multidetector-row CT is the imaging modality of choice in these patients. The authors will review the different types of imaging work-up and management of patients with acute lower gastrointestinal bleeding.

Pain as the only consistent sign of acute appendicitis: lack of inflammatory signs does not exclude the diagnosis.

BACKGROUND: The clinical diagnosis of acute appendicitis in adults remains tricky, but radiological examinations are very helpful to determine the diagnosis even when the adult patient presents atypically. This study was designed to quantify the proportion of patients with a preoperative diagnosis of acute appendicitis that had isolated right lower quadrant pain without biological inflammatory signs and then to determine which imaging examination led to the determination of the diagnosis. METHODS: In this monocentric study based on retrospectively collected data, we analyzed a series of 326 patients with a preoperative diagnosis of acute appendicitis and isolated those who were afebrile and had isolated right lower quadrant pain and normal white blood cell counts and C-reactive protein levels. We determined whether the systematic ultrasonography examination was informative enough or a complementary intravenous contrast media computed tomography scan was necessary to determine the diagnosis, and whether the final pathological diagnosis fit the preoperative one. RESULTS: A total of 15.6% of the patients with a preoperative diagnosis of acute appendicitis had isolated rebound tenderness in the right lower quadrant, i.e., they were afebrile and their white blood cell counts and C-reactive protein levels were normal. In 96.1% of the cases, the ultrasonography examination, sometimes complemented by an intravenous contrasted computed tomography scan if the ultrasonography result was equivocal, fit the histopathological diagnosis of acute appendicitis. CONCLUSIONS: The diagnosis of acute appendicitis cannot be excluded when an adult patient presents with isolated rebound tenderness in the right lower quadrant even without fever and biological inflammatory signs. In our study, ultrasonography and computed tomography were very helpful when making the final diagnosis.

Multimodal imaging for the detection and characterization of liver lesions in a mouse model of neuroendocrine tumor.

BACKGROUND: The aim of this study was to compare in vivo magnetic resonance imaging (MRI) and ex vivo autoradiography with histopathological results for the detection and characterization of liver lesions in an experimental model of human neuroendocrine tumors. MATERIAL AND METHODS: Intestinal STC-1 endocrine tumor cells were injected into 30 nude mice to achieve hepatic dissemination. Seven to 30 days after injection, T2-weighted in vivo images covering the entire liver were acquired with a 7-T system. Autoradiographs were also obtained in 28 mice after injection of fluorodeoxyglucose (18F-FDG). The autoradiographic liver samples were then stained with an antichromogranin antibody before histological analysis. Tumor size and the hepatic tumor fraction were measured using the three imaging modalities. RESULTS: Metastatic tumors visualized on the histological liver sections ranged in size from 50 microm (day 7) to 3 mm (day 30). The hepatic tumor fraction increased with time, reaching 30% of the hepatic surface area on day 30. Visual analysis revealed variable tumor distribution and type (solid and/or cystic). On MRI, lesions were identified from day 12 (about 100 icrom in diameter) and the hepatic tumor fraction was up to 48% at day 30. The smallest lesions (350 microm in diameter) were also detected at day 12 on the autoradiographs. There was good correlation between tumor fractions determined from autoradiographic and histological data. CONCLUSION: In vivo, MRI appears to be well suited to the follow-up of liver lesions in a mouse model of neuroendocrine tumor. Preliminary results using 18F-FDG in this animal model are promising, showing differences in FDG uptake.

A magnetic resonance elastography (MRE) approach for liver investigation.

Due to its key role in carbohydrate metabolisation, blood detoxification, filtering and substance storing, liver is prone to a wide variety of diseases: hepatitis, cirrhosis, cancer. As such, liver investigation is a major field of interest. We describe here a non invasive way to obtain important information on liver elasticity properties. In vitro Magnetic Resonance Elastography (MRE) experiments are realized using a normalized substance (Agar gel in different concentrations) and this technique is also demonstrated in the context of an in vivo investigation of the elastic properties of a normal control liver.

Characterization of neuro-endocrine tumors in an athymic nude mouse model using dedicated synchronization strategies for T2-weigted MR imaging at 7T.

Endocrine tumours, with digestive localization, are tumours with variable forecast which are independent of their invasive and metastatic extensions. The experimental model of endocrine tumors with liver dissemination is available for evaluation of new medical therapeutics such as antiangiogenic therapy. MRI is a non invasive modality allowing in vivo examinations and is suitable to follow liver lesion evolution during longitudinal study on animal models. The goal of this study was to assess the detection level and to characterize the liver lesions in an athymic nude mouse model, using a dedicated MRI protocol and an optimized synchronization strategy at high magnetic field strength. The experiments were performed at 7T. To detect liver lesions, respiratory-triggered T2-weighted MR images is the sequence of choice. With conventional acquisition strategies used on small animal MR systems, trigger signal is performed at each respiratory cycle and thus, the T2 contrast is not freely controlled. Additionally, the slice number is limited by the expiration delay. To overcome these drawbacks, we proposed an original strategy enabling true T2-weighted imaging with minimal movement artifacts, regardless of the respiratory period and the number of slices. This protocol was used to carry out a longitudinal follow-up of hepatic lesions in 8 nude mice at stages D7, D12, D17 and D24. The fraction of lesion over the total liver volume was quantified. Moreover, the characterization of cystic or non-cystic type of lesions was achieved using various TE leading to T2 maps. In conclusion, the level of lesion detection and characterization of liver lesions was performed using a devoted protocol with original synchronization strategy dedicated to high field MRI. MR imaging could be used with relevance in the evaluation of new therapeutics protocol for treatment of liver lesions in neuroendocrine tumors using small animal model.

[Value of MRCP with Mangafodipir Trisodium (Teslascan) injection in the diagnosis and management of bile leaks]. / Intérêt de la cholangio-IRM avec perfusion de Mangafodipir Trisodium (Teslascan) dans le diagnostic topographique et la prise en charge des fuites biliaires.

PURPOSE: To assess the value of MRCP with Mangafodipir Trisodium (Teslascan) injection in the diagnosis and management of bile leaks. PATIENTS AND METHODS: Retrospective study of 25 patients (18 males, 7 females) with a mean age of 49.7 years and high clinical suspicion of bile leak who underwent MRCP with Mangafodipir Trisodium (Teslascan) injection between 2002 and 2006. The suspected etiology for bile leak was surgical (n=17), traumatic (n=7) or medical (n=1). The clinical suspicion was based on a combination of clinical, laboratory and imaging findings. RESULTS: MRCP with Teslascan injection demonstrated a bile leak in 20 patients. The site of leak was depicted in 17 cases: second order of smaller bile duct, (n=9), hepatic duct (n=3), confluence (n=2), cystic duct (n=1), bilioenteric anastomosis (n=2). Management based on MR findings included biloma drainage (n=7), biliary drainage (n=5), endoscopic management (n=2), repeat surgery (n=3), expectant management (n=1), and medical management (n=1). Outcome was favourable in 18 cases. Two patients died from infectious complications. CONCLUSION: In addition to confirming a diagnosis of bile leak, MRCP with Teslascan injection depicts the site of leak allowing optimal management.

[Asymptomatic or paucisymptomatic CBD dilatation on US after cholecystectomy: management]. / Dilatation a- ou pauci-symptomatique de la voie biliaire principale découverte en échographie chez un(e) patient(e) cholécystectomisé(e). Quelle conduite à tenir?

In western countries, 10-15% of the population has gallbladder stones with 46,000 cholecystectomies performed in France in 2003. So, daily ultrasonography of the abdomen performed in patients without gallbladder is a routine exam. However, identification of an enlarged common bile duct is frequent and the normal nature of this finding remains uncertain. The purpose of this article is to perform a literature review of the impact of cholecystectomy on the diameter of the common bile duct. Furthermore, it is important not to dismiss common bile duct dilatation after cholecystectomy because it may be the result of post operative complication or secondary to a congenital disease of bile duct.

[Von Meyenburg disease found during laparoscopic surgery: report of two cases]. / Maladie des complexes de von Meyenburg (micro-hamartomes biliaires) découverte lors d'une chirurgie laparoscopique: à propos de deux observations.

The authors report two cases of von Meyenburg complexes disease found during laparoscopic surgical procedures. The first patient (41 years old) had multiple gallbladder stones with recurrent hepatic colics. The second patient (45 years old) had gastroesophageal reflux with recurrent peptic esophagitis. In both cases, multiple millimetric and superficial hepatic lesions were found during the exploration of the abdominal cavity. Then, an hepatic biopsy was done because the macroscopic aspect should suspect secondary metastatic lesions. Histological result made the diagnosis of von Meyenburg complexes disease (biliary microhamartomas). It seems to be important to know this anomaly of the ductal plate development and to do a liver biopsy during laparoscopy to affirm the diagnosis and cancel the diagnosis of multiple hepatic metastasis. In fact, this congenital pathology could be associated with increased risk of cholangiocarcinoma of the liver. The modality of radiological monitoring still remains to be defined.

[Value of contrast-enhanced MR enterography in pediatric Crohn's disease: preliminary study]. / Valeur de l'entéro-IRM avec injection de gadolinium dans la maladie de Crohn en pédiatrie: étude préliminaire.

OBJECTIVE: Feasibility study of contrast enhanced MR enterography without enteroclysis as a new diagnostic tool for children with known or suspected Crohn's disease. METHODS: We prospectively included 15 children, 8-18 years old, with clinical suspicion of Crohn's disease. MR enterography without enteroclysis was performed on a 1,5 T clinical MR system. A total of 1000 ml of mannitol 5% was orally administered 60 minutes prior to MRI. Coronal and axial breath-hold sequences were acquired. The following sequences were obtained: True-FISP, FLASH T1 2D/3D with Fat saturation before and after gadolinium injection. Two radiologists, blinded to patient information, independently reviewed all examinations to record image quality, the degree of distension of the distal ileum, the presence of abnormal bowel segments and the presence of extra-intestinal complications. MRI findings were correlated to sonographic, endoscopic and biological results (sensitivity, specificity, Kappa test). RESULTS: The examinations were considered of satisfactory diagnostic quality in 93.3% of patients. Respiratory artifacts were present in one case. The entire GI tract could be identified on all sequences. Distention of the distal ileum was recorded as good to excellent in 89% of healthy subjects. Five MR examinations were considered abnormal with isolated ileal involvement in 2 cases, ileocolic involvement in 2 cases, and isolated colonic involvement in 1 case. The sensitivity and specificity of MR for the positive diagnosis of Crohn's disease were 100% and 83% respectively. Three extra-intestinal complications were detected: one case of ileo-ileal fistula, not identified on ultrasonography, an asymptomatic anal fistula and a symptomatic inflammatory stricture. CONCLUSION: MR enterography without enteroclysis is a well tolerated, effective non invasive method in the evaluation of known or suspected Crohn's disease. Because of the absence of ionizing radiation, MR enterography should become the gold standard in pediatric patients.

Pneumatocele formation in adult Escherichia coli pneumonia revealed by pneumothorax.

Pulmonary pneumatoceles are a rare complication of nosocomial pneumonia. They occur most often in staphylococcal infections and are hence more frequent in children. We report the case of an immunocompromised adult who shortly after digestive surgery developed Escherichia coli pneumonia which evolved rapidly towards pneumatocele formation revealed by pneumothorax.