[Gastric and pancreatic cancers: Will neoadjuvant (chemo)radiotherapy replace adjuvant chemoradiotherapy?] / Cancers gastriques et pancréatiques : la (chimio)radiothérapie néoadjuvante remplacera-t-elle la chimioradiothérapie adjuvante ?

For many years, adjuvant chemoradiotherapy remained essential in the therapeutic management of gastric and pancreatic adenocarcinomas. For these tumours, surgical excision, the only hope of offering the patient prolonged survival, is only possible in 20% of cases. The median survival of operated patients is only 12 to 20 months due to the frequency of locoregional and/or metastatic recurrences. For stomach cancers, adjuvant chemoradiotherapy is justified by the results of the phase III trial Intergroup 0116 published by MacDonald et al. The gain in survival was at the cost of significant toxicity. This treatment was supplanted in the early 2000s by perioperative chemotherapy. Currently, neoadjuvant chemoradiotherapy clinical studies are ongoing with the aim of improving treatments observance and tolerance. For pancreatic cancers, the role of adjuvant chemoradiotherapy has long been discussed because of trials with contradictory results. Neoadjuvant radiotherapy has many advantages in terms of efficacy and tolerance. It increases the chances of subsequent complete tumour resection. Several prospective trials are currently ongoing to clarify its place in the therapeutic arsenal.

[Adjuvant chemotherapy followed by conformal chemoradiotherapy in gastric carcinoma]. / Chimiothérapie adjuvante suivie d'une chimioradiothérapie conformationnelle dans les cancers de l'estomac.

PURPOSE: Analysis of the feasibility and results of adjuvant chemotherapy followed by conformal chemoradiotherapy after surgery for gastric carcinoma. PATIENTS AND METHODS: Twenty-six patients (R0 or R1) were treated postoperatively by three cycles of 5-fluorouracil (5-FU) and cisplatin, followed by a concomitant association of LV5FU2 chemotherapy with a conformal radiotherapy of 45 Gy. RESULTS: The tumor was classified pT3-T4 in 77% of the patients and 92.5% had a nodal involvement (pN1: 54%; pN2: 31%). FEASIBILITY: (1) Adjuvant chemotherapy: nausea/vomiting grade II/III: 12 patients (48%); neutropenia grade III/IV: two patients; completed in all patients, except one. (2) Chemoradiotherapy: nausea/vomiting grade II/III: 10 patients; diarrhea grade II/3: two patients; oesophagitis grade II/III: two patients; myocardial infarction/pulmonary embolism: two patients. All patients except one received the planned dose of 45Gy. Radiotherapy was interrupted in six cases, with a median duration of 14 days. Survival: with a median follow-up of 30 months, 65% of the patients were alive without disease; median survival was 32 months. CONCLUSION: This postoperative schedule was judged feasible. It allowed the deliverance of a more intensified chemotherapy than the classical schedule. Its clinical benefit must be evaluated in a phase III trial.

[Conformal radiotherapy of prostate cancer]. / Radiothérapie conformationnelle du cancer de la prostate: technique et résultats.

A number of retrospective and prospective studies have demonstrated that radiotherapy of prostate cancer must be actually conformal. Three-dimensional (3D) treatment planning consists in an as accurate as possible definition of target-volume, usually by CT-scan, and design of radiation fields shaped to this target-volume. Several steps are required, each step being important for the overall quality of the treatment. Conformal radiotherapy is better tolerated than conventional irradiation, with significantly less rectal toxicity. It allows dose-escalation up to 80 Gy. It is now possible to go beyond this dose with intensity-modulated radiotherapy. The benefit of these high doses was demonstrated by some large retrospective studies and some prospective dose-escalation trials. Several randomized trials are in progress, preliminary results of two of them have been published, both showing an improvement in disease control with the higher doses. The advantage of higher doses is clearly evident for patients in the intermediate prognostic group, but is still discussed for patients with a low risk tumour or treated in combination with hormone therapy. Late proctitis is the main toxicity of these high doses. Some volume constraints have been defined during the last years and will allow a decrease of the rate of rectal toxicity. Because of these technological improvements, results of radiation therapy are now similar to those of surgery: no direct comparison with a randomized trial is available, but large comparative studies show that long-term disease control are identical with both techniques. Radiation therapy must be proposed to all patients with a prostate carcinoma as an alternative to surgery.

Selection of diabetic patients for islet transplantation. A single-center experience.

OBJECTIVE: Since the Edmonton protocol, islet transplantation (IT) offers the prospect of adequate glycemic control with no major surgical risk. In our single-center experience of IT, we studied the recruitment of eligible diabetic patients. METHODS: Between 1998 and 2002, we screened 79 diabetic patients that were divided into 2 groups according to their renal status: 41 were not receiving dialysis (ND) while 38 were receiving ongoing dialysis (D). RESULTS: In the ND group, 20 patients initiated the contact with our team, 8 patients were recruited during hospitalization for very poor glycemic imbalance, and 13 were referred by their diabetologist. 14/41 (34%) patients were ineligible for IT either because of very good glycemic balance, detectable C-peptide (C-p), kidney or liver problems, or plans for future pregnancy. 16/41 (39%) did not wish to proceed, 7 of whom were more interested by a pump. 11/41 (27%) were eligible, among which 8 are currently being assessed, 1 is on the waiting list and 2 have been transplanted. In the D group, 17/38 (45%) had a detectable C-p and received a kidney graft alone. Among the remaining 21 C-p negative diabetic patients, 3 were not eligible for kidney transplantation mainly for psychological reasons, and 4 were enlisted for kidney+pancreas transplantation. The remaining 14 C-p negative patients were kidney-transplanted. Among them, 6 were not eligible for IT, mainly for lack of motivation, slightly positive C-p stimulation tests, obesity, cancer, or increased creatininemia. The remaining 8/14 C-p negative kidney-engrafted patients were enlisted for IT. 3 had secondary failure with the pre-Edmonton immunosuppressive (IS) protocol. Five have been transplanted with the Edmonton-like IS regimen. CONCLUSION: Twenty-five per cent of the 79 patients for whom islet transplantation was considered underwent pregraft assessment and 12% (10 patients, 8 kidney-transplanted and 2 islet alone) of the 79 have been transplanted. The main eligibility criteria were undetectable Cpeptide, normal kidney function, average weight, glycemic imbalance, hypoglycemia unawareness, and glycemic brittleness.

[Percutaneous biliary prostheses. Type of material and indications]. / Les prothèses biliaires percutanées. Type de matériel et indications.

The results of percutaneous transhepatic endoprosthesis in the treatment of biliary stenosis are discussed on the basis of the reports of the literature and a personal experience of more than 400 patients treated for about 15 years. Advantages and disadvantages of conventional stents as compared with metal endoprosthesis are discussed, the latter being now preferred by most authors. However they do not prove to be more efficient than conventional stents which are suitable for those patients who have a relatively short life expectancy. Percutaneous treatment of benign biliary stenosis has grown as well but the choice of the best procedure remains difficult. Metal endoprostheses are controversial because the risk of delayed obstruction has not yet been clearly evaluated. However it might become an interesting therapeutic procedure in the future.

[Factors of image quality in spiral x-ray computed tomography]. / Facteurs de qualité de l'image en scanner spiralé.

In helical CT, there are 4 mains factors of quality: The in-plane spatial resolution that is the same in conventional CT; The spatial resolution on the Z axis, which is the slice thickness. The increase factor of the slice thickness between a conventional and a helical CT depends on the pitch and the reconstruction algorithm. The value of the increase factor can be easily calculated; The signal to noise ratio which depends on the collimation, the mA, the KV and the reconstruction algorithm. The signal to noise ratio is not depending on the table speed; The reconstruction interval which can be less than the slice thickness. Then the contrast of small lesion is improved and stair-step artifacts are reduced in 3D reformations.

[Interventional MRI. Analysis of data and prospects]. / IRM interventionnelle. Analyse de données et perspectives.

In spite of its many advantages: 3D imaging, improved tissue characterization, and lack of ionizing radiation, interventional MRI remains seldom used. Several factors are involved. The purpose of this paper is to analyze the factors preventing or slowing the development of this technique based on a review of data from the literature, work presented at the second symposium on interventional MRI (Düsseldorf, 1997), and our own experimental data. The following elements will be discussed: difficulties related to image quality and open magnets, control of targeted image acquisitions, MR environment and problems related to asepsis, as well as advances of other techniques. Finally, short-term and mid-term perspectives will be presented. These are related to the goals of the technique: open or short bore closed magnets? MR unit installed in a radiology department? MR unit dedicated to interventional procedures only or mixed diagnostic-interventional unit? interventional MR unit placed in a neurosurgery operating room? interventional MR unit installed in a general surgery operating room?

CT and MRI imaging at the acute phase of inaugural non-traumatic hepatic haemorrhages.

PURPOSE: Although rare, non-traumatic hepatic haemorrhage is a known complication of liver tumors. In cases where the haemorrhage is the first clinical event, diagnostic work-up is critical. MATERIAL AND METHODS: This retrospective study was conducted between July 2001 and March 2011. Acute phase CT-scan and MRI imaging in patients diagnosed with non-traumatic liver hematomas were interpreted with particular attention to the radio-semiotic characteristics of hematomas and liver lesions. Those findings were then confronted to the patients' final diagnoses. RESULTS: Twelve patients were included (mean age of 42 years). In seven of them a suspect liver lesion was discovered in the acute CT-Scan or MRI imaging. All lesions were strongly hyper vascular.The haemorrhage revealed hepatocarcinoma in four patients, liver adenoma in two and focal nodular hyperplasia in an other. CONCLUSION: It is important in spontaneous liver haemorrhage to consider the high probability of hepatocarcinoma or potentially malignant lesions even when the patient has no known hepatic disorders, and especially in young patients. The results of this study show that imaging is a key issue at the acute phase of inaugural non-traumatic hepatic haemorrhages and requires a simple but complete triphasic injected protocol.

Safety and efficacy of sorafenib in hepatocellular carcinoma: the impact of the Child-Pugh score.

BACKGROUND: Sorafenib increases median survival and time to radiological progression in patients with advanced hepatocellular carcinoma, but its benefit for Child-Pugh B patients remains uncertain. AIM: To evaluate the safety and efficacy of sorafenib in real-life clinical practice conditions and to assess the influence of Child-Pugh class B on safety and efficacy. METHODS: All patients treated with sorafenib for advanced hepatocellular carcinoma in our institution were included prospectively. Adverse events, overall survival and time to progression were recorded. A case control study was performed to compare outcome of patients with comparable stages of hepatocellular carcinoma, but a different Child-Pugh class. RESULTS: From March 2007 to May 2009, 120 patients were included. Overall survival was 11.1 months, Child-Pugh A patients (n=100) had significantly higher median survival than Child-Pugh B patients (n=20) (13 vs. 4.5 months, P=0.0008). In multivariate analysis, Child-Pugh class B, α-fetoprotein level and total size of lesions were independent predictive factors of death. Patients with radiological progression in the first 3 months had shorter median survival (5.4 vs. 17.4 months). In a case control study, time to symptomatic progression (2.5 vs. 3.6 months), frequency of adverse events and discontinuation of sorafenib were not correlated with Child-Pugh class. CONCLUSIONS: Patients with advanced hepatocellular carcinoma treated with sorafenib had a median survival of 11 months. Sorafenib therapy must be considered with caution in Child-Pugh B patients due to their poor survival. Radiological assessment of tumour progression at an early stage may be advantageous when tailoring sorafenib therapy.

Oral administration of a low-cost negative contrast agent: a three-year experience in routine practice.

A low cost, well tolerated, and effective gastrointestinal contrast agent is needed for abdominal MRI. The authors tested, in vitro and in routine practice, a mixture of 192 g of barium sulfate (Micropaque HD oral, Guerbet, France) diluted in 500 ml of gastric antacid (Maalox, Rohrer, Fort Washington, PA). Its T1 and T2 relaxation times were 324 and 14 msec, respectively (.2 T). This contrast agent was used in routine practice in 789 patients (.5 T). It had a low signal intensity in 86% and 82% of the cases on T1- and T2-weighted sequences, respectively. No side effect due to magnetic susceptibility was seen, even with gradient-echo sequences. The dilution of barium sulfate in gastric antacid, instead of water, causes a low signal intensity on all sequences for a low barium sulfate concentration (38% w/v). This product is an effective and low cost contrast agent in routine practice.

Arterial complications of percutaneous transhepatic biliary drainage.

PURPOSE: To report on the frequency and treatment of arterial complications due to percutaneous transhepatic biliary drainage (PTBD). MATERIALS: Lesions of the intrahepatic artery were encountered in 10 of 525 patients treated by PTBD (2%). Hemobilia followed in 9 patients and subcapsular hematoma in 1. Seven patients had a benign biliary stenosis and 3 had a malignant stenosis. RESULTS: The bleeding resolved spontaneously in 3 patients. In 7 it required arterial embolization, which was successfully achieved either through the percutaneous catheter (n = 3) or by arteriography (n = 4). CONCLUSION: Arterial bleeding is a relatively rare complication of PTBD that can easily be treated by selective arterial embolization when it does not resolve spontaneously. In this series its frequency was much higher (16%) when the stenosis was benign than when it was malignant (0.6%).

CT-guided percutaneous drainage of an anterior mediastinal abscess with a 16 F catheter.

We report a case of anterior mediastinal abscess treated by percutaneous drainage under computed tomography (CT) guidance. The relationships of the abscess to the adjacent organs were clearly delineated by an intravenous injection of contrast material, and the drain was inserted between the sternum and the vasa thoracica interna. Selection of this route and the choice of a large-bore catheter (16 F) are discussed.

Treatment of hepatocellular carcinoma by transcatheter arterial chemoembolization: comparison of planned periodic chemoembolization and chemoembolization based on tumor response.

OBJECTIVE: The purpose of our study was to assess the efficacy of transcatheter arterial chemoembolization in the treatment of hepatocellular carcinoma using two different infusion schedules. MATERIALS AND METHODS: Chemoembolization with lipiodol-mediated injection of doxorubicin was performed in 160 patients. In the first group of 80 patients, conventional chemoembolization was initially planned to be repeated at least three times at 2-month intervals. In the second group of 80 patients, chemoembolization was used selectively and repeated only when necessary on the basis of follow-up CT or MR imaging. According to the Okuda classification, 72 patients were stage 1, 33 belonging to group 1 (subgroup 1, Okuda 1) and 39 belonging to group 2 (subgroup 2, Okuda 1). Eighty-eight patients were stage 2, 47 belonging to group 1 (subgroup 1, Okuda 2) and 41 belonging to group 2 (subgroup 2, Okuda 2). RESULTS: Complications of transcatheter arterial chemoembolization occurred in 19 patients from group 1 and six patients from group 2 (p < .001). The mean time between the first and the third courses was significantly different between group 1 (4 months) and group 2 (14 months) (p < .001). The 1-year, 2-year, and 3-year survival rates were significantly different between subgroup 1, Okuda 1, (58%, 28%, 11%) and subgroup 2, Okuda 1 (89%, 68%, 39%) (p <. 001), and between subgroup 1, Okuda 2 (19%, 0%, 0%), and subgroup 2, Okuda 2 (48%, 31%, 15%) (p < .001). CONCLUSION: The efficacy and tolerability of chemoembolization increase when it is used selectively and repeated only when necessary. Such technical considerations might explain some of the discrepancies of the results of chemoembolization in published data.

Caroli's disease: a magnetic resonance cholangiopancreatography diagnosis.

Magnetic resonance cholangiopancreatography (MRCP) has received much attention in the recent literature as a noninvasive alternative to endoscopic retrograde cholangiography, primarily for biliary calculus disease, but also for the less common indication of evaluation of biliary anomalies. We present a case of Caroli's disease in which the diagnosis can be clearly inferred by MRCP. The findings of MRCP and endoscopic retrograde cholangiopancreatography are similar. This new procedure could be a noninvasive alternative to direct cholangiography and perhaps will become the first-choice imaging technique for diagnosing Caroli's disease.

Biliary leaks: treatment by means of percutaneous transhepatic biliary drainage.

PURPOSE: To evaluate the efficacy of percutaneous transhepatic biliary drainage in the treatment of biliary leaks. MATERIALS AND METHODS: Sixteen patients with a biliary leak involving either the common bile duct (n = 12), the biliary confluence (n = 2), or a hepaticojejunal anastomosis (n = 2) were treated by means of percutaneous transhepatic biliary drainage. The biliary leak was due to severe acute necrotizing pancreatitis in six patients, while 10 patients had postoperative leak. Percutaneous transhepatic biliary drainage was performed with a 12-F catheter, with two series of side holes positioned on both sides of the extravasation to divert bile flow away from the defect. RESULTS: In 13 patients, the biliary leak healed after drainage (mean duration, 78 days). In four of these patients, a slight residual narrowing of the bile duct was treated by means of either balloon dilation (n = 2) or balloon dilation followed by insertion of a metallic stent (n = 2). All 13 patients remained cured (mean follow-up, 38 months). Two patients with severe acute necrotizing pancreatitis died of complications unrelated to the biliary leak. Vascular complications occurred in two patients, one of whom died after surgical drainage of a subcapsular hematoma. CONCLUSION: Biliary leaks can be treated successfully by means of percutaneous transhepatic biliary drainage. The procedure is particularly useful when surgical or endoscopic management has failed.