Safety and efficacy of low-dose PI3K inhibitor taselisib in adult patients with CLOVES and Klippel-Trenaunay syndrome (KTS): the TOTEM trial, a phase 1/2 multicenter, open-label, single-arm study.

PURPOSE: PIK3CA pathogenic variants in the PIK3CA-related overgrowth spectrum (PROS) activate phosphoinositide 3-kinase signaling, providing a rationale for targeted therapy, but no drug has proven efficacy and safety in this population. Our aim was to establish the six-month tolerability and efficacy of low-dose taselisib, a selective class I PI3K inhibitor, in PROS patients. METHODS: Patients over 16 years with PROS and PIK3CA pathogenic variants were included in a phase IB/IIA multicenter, open-label single-arm trial (six patients at 1 mg/day of taselisib, then 24 at 2 mg/day). The primary outcome was the occurrence of dose limiting toxicity (DLT). Efficacy outcomes were the relative changes after treatment of (1) tissue volume at affected and unaffected sites, both clinically and on imaging; (2) cutaneous vascular outcomes when relevant; (3) biologic parameters; (4) quality of life; and (5) patient-reported outcomes. RESULTS: Among 19 enrolled patients, 2 experienced a DLT (enteritis and pachymeningitis) leading to early trial termination (17 treated, 10 completed the study). No serious adverse reaction occurred in the 1 mg cohort (n = 6). No significant reduction in affected tissue volume was observed (mean -4.2%; p = 0.81; SD 14.01). Thirteen (76.4%) participants reported clinical improvement (pain reduction, chronic bleeding resolution, functional improvement). CONCLUSION: Despite functional improvement, the safety profile of low-dose taselisib precludes its long-term use.

The infragluteal fold: An appraisal by MRI combined with an anatomic study.

PURPOSE: The gluteal region is a key element of beauty balance and sexual appearance. However, there is no clear anatomical description of the infragluteal fold, nor any classification exists allowing standardizing treatment of this area in case of jeopardisation. The purpose of this study was to perform an anatomical description of the infragluteal fold (IGF) matching radiological and anatomical findings in describing specifically raise of the fibrous component at the bone level. METHODS: Six volunteers (three males and three females) underwent an MRI scan (Siemens Aera® 1.5 T) of the pelvic region. T1 Vibe Morpho T2, Sag Space 3D, and Millimetric slices were performed in order to obtain a more detailed selection of the gluteal landmark. Trabecular connective tissue of the region was analyzed using Horos® ROI (region of interest) segmentation function. Four fresh cadavers (two males, two females, accounting for 8 hemipelvis) were dissected in order to compare the radiological findings. RESULTS: The infragluteal fold is a connectival fibrous band extending from the ramus of the ischium (but not involving the ischial tuberosity, for a length of 21 mm ± 2 and 21 mm ± 3), the apex of the sacrum (for a length of 13 ± 2 and 11 mm ± 2), and the coccyx (for a length of 19 mm ± 2 and 20 mm ± 2, all measures referring to volunteers and cadavers, respectively) reaching superficially the dermis of the medial one-third of the cutaneous fold. No significant difference was found between volunteer and cadaver group in MRI measurement of bony origins, or between MRI and cadaveric dissection measurements. CONCLUSION: Knowledge of this structure will define novel surgical techniques in infragluteal fold restoration.

European Association for the Study of the Liver (EASL), European Association for the Study of Diabetes (EASD) and European Association for the Study of Obesity (EASO) clinical practice recommendations for the management of non-alcoholic fatty liver disease: evaluation of their application in people with Type 2 diabetes.

AIMS: To evaluate the application of the recently proposed recommendations by the European Association for the Study of the Liver, European Association for the Study of Diabetes and European Association for the Study of Obesity for the diagnosis, treatment and follow-up of non-alcoholic fatty liver disease in people with Type 2 diabetes. METHODS: A total of 179 people with Type 2 diabetes were included in this study. Liver fat content (assessed using proton magnetic resonance spectroscopy), fatty liver index score, non-alcoholic fatty liver disease fibrosis score, and SteatoTest and FibroTest scores were determined. RESULTS: According to proton magnetic resonance spectroscopy, 68.7% of participants had steatosis (liver fat content >5.5%). The application of the guidelines using several combinations (fatty liver index + non-alcoholic fatty liver disease fibrosis scores, Steatotest + FibroTest scores, proton magnetic resonance spectroscopy + non-alcoholic fatty liver disease fibrosis score, proton magnetic resonance spectroscopy + FibroTest) resulted in a referral to a liver clinic for 33.5-84.9% people with Type 2 diabetes. CONCLUSIONS: The application of these new algorithms for the diagnosis, and follow-up of non-alcoholic fatty liver disease would lead to an excessive number of people with Type 2 diabetes being referred to a liver clinic. We suggest that new clinical and/or biological biomarkers of steatosis and fibrosis be specifically validated in people with Type 2 diabetes.

Reliability and reproducibility of the American Association for the Surgery of Trauma scaling for renal injury and impact on radiologic follow-up.

INTRODUCTION: The American Association for the Surgery of Trauma (AAST) Organ Injury Scale (OIS) is the most used classification for renal trauma. It determines the radiologic monitoring, only recommended for high-grade injuries. The aim of this study was to assess the subjectivity of AAST scaling and its impact on short-term follow-up. METHODS: We retrospectively reviewed all patients with blunt renal injuries admitted at a university hospital between 2010 and 2015. Computed Tomography (CT) scan were analyzed and injuries graded according to AAST OIS independently by a senior radiologist, a senior urologist who was blind to clinical data and a resident urologist. Grading disagreements were analyzed collegially to obtain a final rating. The agreement of AAST scaling was evaluated through the Cohen's Kappa coefficient. RESULTS: Ninety-seven patients had 101 renal injuries: low grade in 58.4% (11.9% grade I, 17.8% grade II, 28.7% grade III) and high grade in 41.6% of cases (23.6% grade IV and 17.8% grade V). The agreement was fair with Kappa coefficient at 0.36. The agreement was moderate in severity sub-division analysis (low or high grade): Kappa coefficient at 0.59. There was a disagreement in 49.5% between the senior urologist's and the senior radiologist's ratings. Those differences brought to a severity group change and radiologic follow-up modification in 34% (n=17). CONCLUSION: AAST OIS for renal trauma suffers from subjectivity but is improved by severity sub-group analysis. This subjectivity influences the radiologic follow-up but could be reduced by collegiate rating. LEVEL OF EVIDENCE: 4.

Multidisciplinary management strategies for acute non-variceal upper gastrointestinal bleeding.

BACKGROUND: The modern management of acute non-variceal upper gastrointestinal bleeding is centred on endoscopy, with recourse to interventional radiology and surgery in refractory cases. The appropriate use of intervention to optimize outcomes is reviewed. METHODS: A literature search was undertaken of PubMed and the Cochrane Central Register of Controlled Trials between January 1990 and April 2013 using validated search terms (with restrictions) relevant to upper gastrointestinal bleeding. RESULTS: Appropriate and adequate resuscitation, and risk stratification using validated scores should be initiated at diagnosis. Coagulopathy should be corrected along with blood transfusions, aiming for an international normalized ratio of less than 2·5 to proceed with possible endoscopic haemostasis and a haemoglobin level of 70 g/l (excluding patients with severe bleeding or ischaemia). Prokinetics and proton pump inhibitors (PPIs) can be administered while awaiting endoscopy, although they do not affect rebleeding, surgery or mortality rates. Endoscopic haemostasis using thermal or mechanical therapies alone or in combination with injection should be used in all patients with high-risk stigmata (Forrest I-IIb) within 24 h of presentation (possibly within 12 h if there is severe bleeding), followed by a 72-h intravenous infusion of PPI that has been shown to decrease further rebleeding, surgery and mortality. A second attempt at endoscopic haemostasis is generally made in patients with rebleeding. Uncontrolled bleeding should be treated with targeted or empirical transcatheter arterial embolization. Surgical intervention is required in the event of failure of endoscopic and radiological measures. Secondary PPI prophylaxis when indicated and Helicobacter pylori eradication are necessary to decrease recurrent bleeding, keeping in mind the increased false-negative testing rates in the setting of acute bleeding. CONCLUSION: An evidence-based approach with multidisciplinary collaboration is required to optimize outcomes of patients presenting with acute non-variceal upper gastrointestinal bleeding.

Interventional radiology for hepatocellular carcinoma.

Hepatocellular carcinoma (HCC) is one of the most frequent primary malignant tumors in the world. Hepatic resection and liver transplantation are considered optimal for potential treatment of HCC. However, only 20% of HCCs can be surgically treated. And most of surgically-noneligible patients have to receive locoregional image-guided interventional managements including intra-arterial and percutaneous ablative therapies. In this paper, we review these interventional approaches. Catheter-based therapies include embolotherapy/chemotherapy-based treatments (such as transarterial chemoembolization, bland embolization, transcatheter arterial chemoinfusion, and chemoembolization with drug-eluting beads), and radiotherapy-based treatments (such as radioembolization with yttrium-90 and injection of iodine-131-labeled lipiodol). Ablative therapeutic approaches include chemical therapies (such as ethanol or acetic acid injection), and thermal therapies (such as radiofrequency ablation, laser induced thermotherapy, microwave ablation, cryoablation, and high-intensity focused ultrasound ablation). Each method has its advantages and drawbacks. As a result of the technical development of locoregional approaches for HCC during the recent decades, the range of combined interventional therapies has been continuously extended. In this article, an evidence-based approach is used to review the current role of interventional radiology in the management of unresectable HCC.

Packing technique for endovascular coil embolisation of peripheral arterial pseudo-aneurysms with preservation of the parent artery: safety, efficacy and outcomes.

OBJECTIVES: To evaluate the endovascular treatment of pseudo-aneurysms (PAs) with super-selective coil embolisation using the 3D packing technique. DESIGN: Retrospective study of consecutive patients in one academic centre. MATERIALS: From 2002 to 2009, 16 patients (mean age 51.6 years, range 24-82) underwent PA sac packing with coils. Four patients were asymptomatic, nine had PA rupture, and three had other symptoms. Lesion location was as follows: splenic artery (8), carotid artery (2), hepatic artery (2), superior mesenteric artery (1), cystic artery (1), uterine artery (1), and hypogastric artery (1). METHODS: The sac was packed with 0.018-inch controlled-detachable microcoils, preserving the parent artery. Magnetic resonance angiography was done within 6 months, at 12 months then yearly. RESULTS: Technical success rate was 100%. Complete definitive PA exclusion was achieved with a single procedure in 15 (93.8%) patients. One patient with a secondary bleeding arterio-digestive fistula underwent successful surgery. No major complications or late recanalisations occurred during follow-up (mean, 24.7 months; range 6-49). CONCLUSIONS: Coil PA embolisation by 3D sac packing is safe and effective and may induce less morbidity than complete parent vessel occlusion, stent placement, or open surgery. This procedure should be used whenever possible, as it preserves parent artery patency.

[Role of percutaneous arterial embolization in renal pathology]. / Place de l'embolisation artérielle percutanée en pathologie rénale.

Therapeutic embolization in renal pathology is used for various conditions in cancerology, traumatology, urology, nephrology and for iatrogenic complications of percutaneous manoeuvers. Any department of vascular radiology may be requested to use this technique, especially in emergent traumatology or palliative cancerology. The authors study the various conditions that may benefit from these procedures and give the highlights of the main indications and the main types of embolic agents used. Complications, side effects and the major precautions are also reviewed.

Endovascular stenting for chronic femoro-iliac venous obstructive disease: Clinical efficacy and short-term outcomes.

PURPOSE: To report the clinical efficacy and mid-term outcomes of endovascular treatment in patients with chronic, symptomatic, post-thrombotic femoro-iliac venous obstruction. MATERIALS AND METHODS: Forty-two patients with post-thrombotic syndrome (PTS) presenting with femoro-iliac venous obstructive lesions treated in our institution by endovascular approach between March 2012 and October 2017 were retrospectively included. There were 27 women and 15 men with a mean age of 47.3±17 (SD) years (range: 22-86 years). Procedure included first venous recanalization, then pre-dilatation and self-expandable metallic stenting of the narrowed or occluded iliac and/or femoral veins. Severity of PTS and quality of life were assessed at baseline and 3 months after the intervention respectively, using Villalta score and Chronic Venous Insufficiency Questionnaire (CIVIQ-20) scale. Imaging follow-up evaluation of stent patency was based on the results of duplex Doppler ultrasound and computed tomography. RESULTS: Immediate technical success was achieved in 41/42 (97.6%) patients, without any major complications. Primary patency, primary assisted patency and secondary patency at the end of the median imaging follow-up of 18.1 months (IQR, 9.7-34.4) were achieved in 29/42 (66.7%) patients, 33/42 (78.6%) patients and 37/42 (88.1%) patients, respectively. Median Villalta and CIVIQ-20 scores decreased from 14 (IQR, 10-19) and 57 (IQR, 39-72) at baseline, respectively, to 5 (IQR, 2-9) and 30 (IQR, 24-50) 3 months after the procedure, respectively (P<0.0001), showing significant decrease in the severity of PTS and improvement in the quality of life. The multiple linear regression model showed that both baseline Villalta and CIVIQ-20 scores ([95% CI: -7.80-3.79; P<0.0001] and [95% CI: 0.07-0.20; P<0.0001], respectively), age (95% CI: 0.04-0.19; P=0.002) and stenting expanse (95% CI: 0.97-5.65; P=0.006) were independent variables related to Villalta gain. Baseline Villalta (95% CI: 0.89-2.23; P<0.0001) was the single independent variable related to CIVIQ-20 gain. CONCLUSION: This study confirms the high clinical efficacy and favorable mid-term outcomes of endovascular stenting in patients with chronic symptomatic femoro-iliac venous obstructive lesions.

[Rotator cuff tears: value of 3.0T MRI]. / Perforations de la coiffe des rotateurs: intérêt de l'IRM 3,0T.

PURPOSE: To demonstrate the value of 3.0T MR imaging for the detection of rotator cuff tendon tears and surgical planning by correlating imaging findings to surgical findings. Materials and methods. Prospective follow-up of patients who underwent 3.0T MR imaging of the shoulder in our department between November 2005 and June 2007. Surgical findings were correlated to imaging findings for 48 patients who underwent surgery: detection, size, partial thickness or complete, and tendon edges. RESULTS: In this patient group, the positive predictive value of MRI for detecting surgical tears was 100% (100% of complete tears and 92% of partial thickness tears). No change in surgical management was recorded when arthroscopy was performed based on MRI findings (size of tear). CONCLUSION: 3.0 T MRI is valuable for the detection of small tears, especially for partial thickness tears due to increased spatial resolution. The identification of surgical candidates and surgical planning are improved due to more accurate measurements of tear size and quality of the tendon edges.

[Fast technique to quantify liver steatosis at 3T: principles, parametric imaging and applications]. / Technique rapide de mesure de la stéatose hépatique à 3T: théorie, imagerie paramétrique, applications.

The purpose of this article is to present a fast and clinically usable technique for quantification of liver steatosis. This technique, based on a triple-echo gradient-echo sequence (in-phase, opposed-phase, in-phase), has recently been validated with excellent correlation and accuracy compared to proton MR spectroscopy. The theoretical principles are reviewed, with emphasis on the need to correct for the T2* decay inherent to the use of in-phase and opposed-phase sequences. T1 decay also is negligible due to the use of a low flip angle (20 degrees). The advantage of this technique is that it can generate a parametric representation (map) of liver steatosis, after fast and simple post-processing, based on measurements from standard images (addition, subtraction, division, multiplication) available on the MR scanning console. This parametric method allows quantification of steatosis in focal lesions. The main limitation of the technique relates to its ambiguity with lipid content over 50%, a phenomenon that does not occur with liver steatosis.

Computer-aided diagnosis system for characterizing ISUP grade≥2 prostate cancers at multiparametric MRI: A cross-vendor evaluation.

PURPOSE: To assess the performance of a computer-aided diagnosis (CADx) system trained at characterizing International Society of Urological Pathology (ISUP) grade≥2 peripheral zone (PZ) prostate cancers on multiparametric magnetic resonance imaging (mpMRI) examinations from a different institution and acquired on different scanners than those used for the training database. PATIENTS AND METHODS: Preoperative mpMRIs of 74 men (median age, 65.7 years) treated by prostatectomy between 2014 and 2017 were retrospectively selected. One radiologist outlined suspicious lesions and scored them using Prostate Imaging-Reporting and Data System version 2 (PI-RADSv2); their CADx score was calculated using a classifier trained on an independent database of 106 patients treated by prostatectomy in another institution. The lesions' nature was assessed by comparison with prostatectomy whole-mounts. Diagnostic accuracy was estimated with areas under receiver operating characteristic curves (AUCs). Sensitivity and specificity were calculated using a CADx threshold (≥0.21) that yielded 95% sensitivity in the training database, and a PI-RADSv2≥3 threshold. RESULTS: A total of 127 lesions (PZ, n=104; transition zone [TZ], n=23) were described. In PZ, CADx and PI-RADSv2 scores had similar AUCs for characterizing ISUP grade≥2 cancers (0.78 [95% confidence interval (CI): 0.69-0.87] vs. 0.74 [95%CI: 0.62-0.82], respectively) (P=0.59). Sensitivity and specificity were respectively 89% (95%CI: 82-97%) and 42% (95%CI: 26-58%) for the CADx score, and 97% (95%CI: 93-100%) and 37% (95%CI: 22-52%) for the PI-RADSv2 score. In TZ, both scores showed poor specificity. CONCLUSION: In this external cohort, the CADx and PI-RADSv2 scores showed similar performances in characterizing ISUP grade≥2 cancers.

[Uterine artery embolization with resorbable material prior to myomectomy]. / Embolisation artérielle utérine par matériel résorbable avant myomectomie.

PURPOSE: Fibroids are a frequent cause of gynecology referral. Myomectomy is a conservative treatment alternative. The main risk from this procedure is hemorrhage. The main objective of this study was to demonstrate the efficacy of preoperative uterine artery embolization with resorbable agents to reduce blood losses and facilitate myomectomy. Secondary objectives were to evaluate morbidity and subsequent fertility. PATIENTS AND METHODS: Retrospective study of 21 patients with preoperative uterine artery embolization prior to myomectomy at the University Medical Center of Dijon over a 3 year period. RESULTS: Myomectomy after uterine artery embolization with resorbable agents was associated with only minimal blood loss. Mean preoperative and postoperative hemoglobin levels were comparable (p<0.0001). Uterine suturing was technically simpler. The number of resected fibroids (p=0.2824) and the presence of preoperative anemia (p=0.474) had no statistically significant impact on the duration of hospital stay. Uterine synechiae occurred in three patients after the procedure, and were easily treated. Two patients had normal subsequent pregnancies. CONCLUSION: Preoperative uterine artery embolization with resorbable agents was effective in reducing surgical blood losses. This technique reduces the number of hysterectomies and hemorrhagic complications (hematoma, infection, weaker scar tissue). It should be considered in patients wishing uterine preservation when the hemorrhagic risk is high. Its use in patients seeking subsequent pregnancy should be further assessed with larger series.

[Xanthogranulomatous pyelonephritis: main imaging features]. / La pyélonéphrite xanthogranulomateuse: principaux aspects en imagerie.

Xanthogranulomatous pyelonephritis is a rare form of chronic pyelonephritis, which frequently has a pseudotumoral appearance, as a result of which differential diagnosis with malignant renal neoplasia is difficult, especially as there are no specific signs of this lesion. The aim of this article is to notice the various histological, clinical and radiological characteristics, and the different modalities of diagnostic and treatment of this affection.

Diffuse xanthogranulomatous pyelonephritis with psoas abscess in a pregnant woman.

We report the first case, to our knowledge, of xanthogranulomatous pyelonephritis (XGP) with psoas abscess occurring during pregnancy. A 37-year-old woman in the third trimester of pregnancy presented with low back pain and a fever. From sonographic features, a multidisciplinary team decided to perform computed tomography of the abdomen with contrast agent injection, which strongly suggested diffuse XGP of the left kidney with a psoas abscess. Cesarean section at 32 weeks was followed by extended nephrectomy. Pathological examination of the operative specimen confirmed the diagnosis. Outcomes were favorable in the mother and baby. The diagnosis and treatment of XGP during pregnancy are discussed.

[Liver steatosis and in-out of phase MR imaging: theory and clinical applications at 3T]. / Stéatose hépatique et séquence phase-opposition de phase: aspects théoriques et applications pratiques à 3T.

Liver steatosis may evolve into steatohepatitis then cirrhosis with related complications. It may also contribute to hepatocellular failure, sometimes fatal after major hepatectomy, especially in the setting of liver transplantation with living donor. Imaging must allow non-invasive detection and accurate quantification. In and out of phase MR imaging routinely performed in clinical practice is a simple and robust means of achieving these goals. In this article, we will review the histological, pathophysiologic, and clinical features of liver steatosis and the key points of in and out of phase pulse sequences and underlying physical principles. The T2* relaxation, cause of a loss of signal between both echo times must be taken into account. Echo times must be known for image interpretation, and optimized, especially at 3T. Finally, the T1 of lipids and water is different and causes T1 effects that may lead to quantification errors while being advantageous for image interpretation. The combination of these factors allows detection and quantification of liver steatosis in routine clinical practice.

Imaging of Von Meyenburg complexes.

Von Meyenburg complexes, or biliary hamartomas, are frequently incidentally detected. They are usually easy to characterize with magnetic resonance imaging. However, in some occasions they are difficult to differentiate from other liver lesions, in particular from small liver metastases. Von Meyenburg complexes are developmental malformations of the ductal plate. They can be found in association with Caroli disease and Caroli syndrome. Like other ductal plate malformations, Von Meyenburg complexes associated with cholangiocarcinoma have been described and their relationship has been established. This review provides an update on the etiopathogenesis of Von Meyenburg complexes, illustrates the imaging features on ultrasound, CT and MRI of this condition and discusses the most common diagnostic pitfalls. The relationships between Von Meyenburg complexes and the various ductal plate malformations and the most recent literature data regarding the relationships between Von Meyenburg complexes and cholangiocarcinoma are presented.

Transjugular intrahepatic portosystemic shunt for acute variceal gastrointestinal bleeding: Indications, techniques and outcomes.

Acute variceal bleeding is a life-threatening condition that requires a multidisciplinary approach for effective therapy. The transjugular intrahepatic portosystemic shunt (TIPS) procedure is a minimally invasive image-guided intervention used for secondary prevention of bleeding and as salvage therapy in acute bleeding. Emergency TIPS should be considered early in patients with refractory variceal bleeding once medical treatment and endoscopic sclerotherapy fail, before the clinical condition worsens. Furthermore, admission to specialized centers is mandatory in such a setting and regional protocols are essential to be organized effectively. This procedure involves establishment of a direct pathway between the hepatic veins and the portal veins to decompress the portal venous hypertension that is the source of the patient's bleeding. The procedure is technically challenging, especially in critically ill patients, and has a mortality of 30%-50% in the emergency setting, but has an effectiveness greater than 90% in controlling bleeding from gastro-esophageal varices. This review focuses on the role of TIPS in the setting of variceal bleeding, with emphasis on current indications and techniques for TIPS creation, TIPS clinical outcomes, and the role of adjuvant embolization of varices.