Primary lower limb lymphoedema: classification with non-contrast MR lymphography.

PURPOSE: The purpose of the present study was to analyse the performance of non-contrast MR lymphography for the classification of primary lower limb lymphoedema in 121 consecutive patients with 187 primary lower limb lymphoedemas. MATERIALS AND METHODS: 121 consecutive patients with clinically diagnosed primary lower limb lymphoedema underwent non-contrast MR lymphography with a free-breathing 3D fast spin-echo sequence with a very long TR/TE (4000/884 ms). MR examinations were retrospectively reviewed for severity of lymphoedema (absent, mild, moderate, severe) and characteristics of inguinal lymph nodes and iliac and inguinal lymphatic trunks graded as aplasic (no lymph nodes or lymphatic trunks), hypoplasic (less lymph nodes or lymphatic trunks), normal and hyperplasic (more lymph nodes or more and/or dilated trunks). RESULTS: There was an excellent correlation between clinical stage and severity of lymphoedema (Cramer's V of 0,73 (p < 0.001)). Differentiation was feasible between inguinal lymphatic vessel aplasia (21%), hypoplasia (15%), normal pattern (53%) and hyperplasia (11%). Severe lymphoedema was observed in 46% of aplasic patterns and in 37% of hyperplasic patterns, but in only 15% of hypoplasic patterns and never observed in normal patterns (p < 0.001). CONCLUSION: Non-contrast MR lymphography is able to classify primary lower limb lymphoedemas into hyperplasic, aplasic, hypoplasic and normal patterns. KEY POINTS: • Non-contrast MR lymphography is able to classify primary lower limb lymphoedemas. • Lymphoedema can be classified in hyperplasic, aplasic, hypoplasic and normal patterns. • Non-contrast MR lymphography can optimize clinical management of primary lower limb lymphoedemas.

[Imaging in oncology: terms and definitions]. / Onkologische Bildgebung: Begriffe und Definitionen.

Oncologic imaging includes the morphological description of the primary tumor region for an accurate classification of the tumor and lymph node stage and whether distant metastases have occurred according to the TNM staging system. Knowing the stage of the disease helps to plan the treatment and to estimate the prognosis. In clinical routine this is accomplished by conventional imaging techniques, such as ultrasound (US), computed tomography (CT) and magnetic resonance imaging (MRI). Additionally, oncologic imaging is essential in treatment monitoring to visualize and quantify the effect of cancer therapy according to response evaluation criteria in solid tumors (RECIST) and World Health Organization (WHO) criteria. The tremendous development in oncology and technical innovations in imaging represent a particular challenge for radiology.

Inter- and intraobserver consistency in assessing eligibility for bevacizumab (BVZ) in non-small-cell lung cancer (NSCLC) patients with centrally located tumors.

BACKGROUND: Bevacizumab (BVZ) combined with platinum-based therapy is registered for first-line treatment of nonsquamous non-small-cell lung cancer (NSCLC). Patients with centrally located tumors are stated ineligible for BVZ treatment. The goal of this study was to assess the consistency in evaluating eligibility of patients with central tumors for BVZ treatment. MATERIALS AND METHODS: The study group was composed of 150 NSCLC patients with centrally located tumors. Eligibility for BVZ was assessed by chest computed tomography (CT) scan. Eligibility was assessed independently using CT images reviewed on workstations. Inter- and intraobserver variations on 50 randomly extracted patients were estimated through a statistical modeling (multiple correspondence analysis). RESULTS: Discordance in eligibility was found for 82 patients (55%). The interobserver strength of agreement was fair to moderate (average kappa = 0.40). Contrarily, the intraobserver strength of agreement was good to very good (average kappa = 0.74). At multivariate analysis, the risk of discrepancy was essentially related to the assessment of the contact between the tumor and the vessels (odds ratio = 13.3, 95% confidence interval 2.8-62.6, P = 0.001). CONCLUSIONS: The consistency in evaluating eligibility of patients with central tumors for BVZ treatment is weak. The study group indicated more stringent criteria to help physicians in taking the best treatment choice that need however to be prospectively validated.

[Cross-sectional imaging of peripheral involvement in ankylosing spondylitis]. / Imagerie moderne des atteintes périphériques dans la spondylarthrite ankylosante.

Ankylosing spondylitis is the most common spondyloarthropathy. It is characterized by enthesopathy (inflammation at the insertion of ligaments, tendons or fascia to bone). The os calcis is most frequently involved. Additional peripheral manifestations include synovitis and dactylitis. Unlike radiographs that demonstrate late manifestations of the disease, ultrasound and MRI demonstrate early inflammatory changes of bones and soft tissues. Multiple sites of involvement may also be detected on a single examination. Both imaging modalities facilitate early diagnosis, a crucial element for patient management. Both modalities may also monitor lesion regression during treatment.

[Imaging of the postsurgical spine]. / Imagerie du rachis lombaire opéré

Some early complications (hematoma, spondylodiscitis, pseudomeningocele) can occur with all types of surgery while late complications vary with the type of surgery. After discectomy, postsurgical changes (osseous and ligamentous defects, scar tissue, granulation tissue) should be distinguished from postsurgical complications or recurrent disease (recurrent disc herniation, arachnoiditis, spondylodiscitis). Following spinal decompression and fusion procedures, standard radiographs and CT can confirm the adequate position of the fusion devices, the presence of fusion, and the development of late osseous complications: pseudarthrosis, instability and recurrent stenosis.

[Diffusion-weighted MR imaging of liver pathology: principles and clinical applications]. / Imagerie par résonance magnétique de diffusion (IRMD) en pathologie hépatique: principe et applications cliniques.

Due to ongoing technological advances, the range of clinical applications for diffusion-weighted MR imaging has expanded to now include abdominal pathology. Current applications for liver pathology include two main directions. First, oncologic imaging with detection, characterization and follow-up of lesions. Second, evaluation of diffuse liver diseases, including hepatic fibrosis. The diagnostic impact and role of diffusion-weighted MR imaging remain under investigation, but appear promising. Because of its short acquisition time, sensitivity, and additional information it provides, diffusion-weighted MR imaging should be included in routine liver imaging protocols.

[Changing paradigms in liver imaging]. / Imagerie du foie.

The landscape of liver imaging today comprises modalities that did not even exist 40 years ago. Conversely, older methods vanished. New technological developments of ultrasound (US), computed tomography (CT), magnetic resonance imaging (MRI) and positron emission tomography (PET) have been such a rushing job that they preceded and even induced changes in medical decision making. Nowadays, these methods have reached their initial goal, mainly anatomical (US, CT, MRI) or metabolic (PET). Therefore, medical strategy, guidelines and standardization occupy now the front of the scene. However, techniques are still headed towards new horizons. This outreach program is functional imaging (perfusion US, CT and MRI of tumors and liver parenchyma), structural imaging (diffusion weighted MRI for fibrosis of tumors, texture analysis in US and CT, MR spectroscopy), "multi-metabolic" imaging (new tracers for PET). All these modalities are new insights into the cell or even the molecule. Adding their strengths, they will also reinforce the concept of hybrid imaging, either by virtue of new combined machines (PET-MRI) or based on new developments of image fusion. The creation of this new knowledge will necessitate remodeling of boundaries between savvy physicians.

[Ultrasound of the Achilles tendon after percutaneous repair]. / Echographie des ruptures du tendon calcanéen après ténorraphie percutanée.

PURPOSE: To evaluate clinical and ultrasound (US) results following percutaneous repair of the Achilles tendon. MATERIALS AND METHODS: Thirty-four patients underwent percutaneous Achilles tendon repair between 2004 and 2006. Seventeen patients (11 males and 6 females aged 30 to 59 years) underwent clinical and US follow-up at a mean of 15 months. US evaluation included assessment of the bilateral Achilles tendons with recording of maximum tendon diameter, echotexture, and presence of intratendonous neovascularization on power Doppler US. RESULTS: On clinical evaluation, all patients were satisfied with the outcome and able to resume their normal level of activity. On US evaluation, there was no tendon discontinuity, and all tendons showed hypoechoic thickening with mean maximal diameter of 13 mm. Focal changes in echotexture were noted in 11 patients, hypoechoic in 5 cases and echogenic in 6 cases. A normal fibrillar echotexture was noted in 5 cases, at more than on eyear after surgery. Intratendonous neovascularization was present in 10 cases, mild in 6 cases, moderate in 2 cases and marked in 2 cases. The degree of neovascularization decreased with increasing postsurgical time. CONCLUSION: Postsurgical Achilles tendons were characterized on US by hypoechoic thickening and loss of normal fibrillar echotexture. The presence of intratendonous neovascularization probably corresponds to postsurgical scarring that decreases over time.

[Focal liver lesions in oncology]. / Lésions hépatiques en cancérologie générale.

In order to improve management of oncologic patients, a standardized 5-step approach should be considered: detection, characterization, locoregional and systemic staging, and post treatment follow up. The use of imaging techniques will be adapted to the clinical question at hand during multi-disciplinary review of cases. The role of the radiologist is to review the indications for each imaging modality and incorporate the results in the clinical context.

[What is the thickness of the normal appendix on MDCT?]. / Quelle est l'épaisseur de l'appendice normal au scanner multibarrette?

OBJECTIVE: To determine the wall thickness and external diameter values of the normal appendix on multidetector computed tomography (MDCT). Materials and methods. A senior radiologist with no knowledge of the patient's surgical history prospectively examined the abdominal-pelvic CT scans of 57 consecutive adult patients with no suspicion for appendicitis. Most of the patients (50/57) received an intravenous iodinated contrast material injection, but none had gastrointestinal studies. All slices (1 and 5 mm) and multiplanar reconstructions were analyzed on a treatment console. The external diameter of the appendix, the thickness of the two appendicular walls, and the presence or absence of intraluminal gas were noted. RESULTS: The appendix was visualized in 82% of the cases (47/57). The mean external diameter was 6.7 mm+/-1.2 (range, 5.0-11.0 mm). The mean thickness of the two walls was 4.8 mm+/-1.0 (range, 2.6-6.4 mm). Intraluminal air was visualized in 87% of cases (41/47). CONCLUSION: Contrary to external diameter, the normal thickness of the appendix's two walls does not go beyond the threshold of 6 mm and therefore seems to be a reliable measurement for identifying a normal appendix using MDCT.

[Gastroduodenal perforation: the role of MDCT]. / Le scanner multi détecteurs améliore la détection des perforations d'ulcères gastro duodénaux.

OBJECTIVE: To determine whether multidetector computed tomography (MDCT) is helpful for early detection of gastroduodenal perforation. MATERIAL AND METHODS: Fifteen consecutive gastroduodenal perforations for ulcer were recorded in the HIS of a single institution. Reports were analyzed and classified according to the following signs: Was a pneumoperitoneum detected? Was there mention of a perforation site, and how was it depicted (axial or reformatted slices, thin or thick slices)? What were the other described features, including peritoneal fluid, abdominal fat blurring, and bowel wall thickening? RESULTS: All patients had a gastroduodenal perforation. MDCT identified pneumoperitoneum in 15 of 15 cases as compared with three of nine cases for plain films. The perforation site was seen in eight of 15: it was identified as a defect in the parietal wall (gastroduodenal). Six of eight cases were depicted in axial view. Two of them were only seen on MPR, coronal or sagittal view. CONCLUSION: MDCT improves the detection rate of pneumoperitoneum and provides critical data for locating the perforation using direct and indirect signs. Multiplanar images seem to improve radiologists' confidence.

[Is appendicolith a reliable sign for acute appendicitis at MDCT?]. / Le stercolithe est-il un signe fiable d'appendicite?

PURPOSE: To determine the frequency of detection of appendicoliths on normal appendix at multidetector row computed tomography (MDCT) with multiplanar reconstructions (MPR). MATERIALS AND METHODS: A senior radiologist, blinded to patient's surgical history, prospectively and independently reviewed abdominopelvic MDCT scans in 57 consecutive adult patients without symptoms suggesting appendicitis. Most patients had IV iodine injection, but no oral contrast. Thick (5 mm) and thin (1 mm) slices were analyzed on a workstation. MPR were available. Localization of the appendix, overall diameter, intraluminal gas and appendicolith were recorded. RESULTS: The appendix was visualized in 47/57 (82%). An appendicolith was found in 13%. Intraluminal gas was identified in 87%. The localization was retrocaecal (47%), mediocaecal (21%) or pelvic (32%). The mean overall diameter of the normal appendix was 6.7 mm +/- 1.2 (SD). CONCLUSION: Appendicolith was found in a significant number of normal patients at MDCT and don't represent a specific sign for appendicitis.

Fotemustine compared with dacarbazine in patients with disseminated malignant melanoma: a phase III study.

PURPOSE: To compare fotemustine and dacarbazine (DTIC) in terms of overall response rate (ORR) as primary end-point and overall survival, duration of responses, time to progression, time to occurrence of brain metastases (BM), and to assess safety and quality of life in patients with disseminated cutaneous melanoma. PATIENTS AND METHODS: Patients received either intravenous fotemustine 100 mg/m2 weekly for 3 weeks or DTIC 250 mg/m2/d for 5 consecutive days every 4 weeks (two cycles). Nonprogressive patients received a maintenance treatment every 4 weeks (fotemustine 100 mg/m2 or DTIC 250 mg/m2 for 5 days). RESULTS: Two hundred twenty-nine patients were randomly assigned to fotemustine or DTIC arms. The best ORR was higher in the fotemustine arm than in the DTIC arm in the intent-to-treat population (n=229; 15.2% v 6.8%; P=.043) and in full analysis set (n=221) (15.5% v 7.2%; P=.053). Similar median durations of responses (5.8 months with fotemustine v 6.9 months with DTIC) and time to progression (1.8 v 1.9 months, respectively) were observed. In patients without BM at inclusion, the median time to BM was 22.7 months with fotemustine versus 7.2 months with DTIC (P=.059). Median survival was 7.3 months with fotemustine versus 5.6 months with DTIC (P=.067). The main toxicity was grade 3 to 4 neutropenia (51% with fotemustine v 5% with DTIC) and thrombocytopenia (43% v 6%, respectively). No significant difference was noted for quality of life between arms. CONCLUSION: ORR was higher in the fotemustine arm compared to the DTIC arm in first-line treatment of disseminated melanoma. A trend in favor of fotemustine in terms of overall survival and time to BM was evidenced.

Preoperative portal vein embolization with a combination of trisacryl microspheres, gelfoam and coils.

PURPOSE: To evaluate the safety and efficiency of preoperative portal vein embolization (PVE) with a combination of trisacryl microspheres, gelfoam and coils for inducing lobar hypertrophy in hepatobiliary malignancy patients. MATERIALS AND METHODS: PVE was performed by a percutaneous left approach in 63 patients with hepatic malignancy (hepatocarcinoma=38, colorectal metastasis=14, cholangiocarcinoma=11). The indication of PVE and surgery was evaluated by hepatic tumor board take into consideration to the tumor extension and the hepatic volume on initial and post-embolization CT-scans. The total functional liver volume (TELV) and future liver remnant (FLR) volume were measured before and 24±5days after PVE to assess FLR, TELV and FLR/TELV ratios. Efficiency evaluation was based on FLR increase, the ability to perform the hepatectomy and the hepatic function after surgery. Safety evaluation was determined by clinical and biological follow-up after embolization and surgery. RESULTS: PVE was successful in all the patients. The mean FLR volume increases by 57±56% after embolization (449±180cm(3) to 663±254cm(3)) (P<0.0001). The FLR/TELV ratio increases by 11% after PVE (25±8% to 36±12%). Three minors' complications were registered without impact on surgery, and four patients developed portal hypertension. Forty-nine patients underwent hepatectomy; none of them developed liver failure. Surgery was not performed in 14 patients due to tumor progression (n=9), inadequate hypertrophy of FLR (n=1) and portal hypertension (n=4). CONCLUSION: Preoperative PVE with a combination of trisacryl microspheres, gelfoam and coils is a safe and effective method for inducing contralateral hypertrophy before right hepatectomy in patients with advanced hepatobiliary malignancy.

A bedside ultrasound sign ruling out pneumothorax in the critically ill. Lung sliding.

STUDY OBJECTIVES: To describe and evaluate an ultrasound pattern useful in the diagnosis of pneumothorax. DESIGN: Ultrasound examination of "lung sliding," a respiratory movement visible when investigating the chest wall. SETTING: The medical ICU of a university-affiliated hospital. PATIENTS: The study group included 43 proved pneumothoraces, either by chest radiograph (n = 40) or by CT (n = 3). The control group included 68 hemithoraces in which the absence of pneumothorax was proved by CT. INTERVENTION: Analysis of anterior chest wall in supine patients. MEASUREMENTS AND RESULTS: Feasibility was 98.1%. Disappearance of "lung sliding" was observed in 100% of 41 analyzable cases of pneumothorax vs 8.8% of the hemithorax without pneumothorax (6 of 68). In this series, sensitivity was 95.3%, specificity 91.1%, and negative predictive value 100% (p < 0.001). CONCLUSIONS: Ultrasound was a sensitive test for detection of pneumothorax, although false-positive cases were noted. The principal value of this test was that it could immediately exclude anterior pneumothorax.

Immediate and long-term results of bronchial artery embolization for life-threatening hemoptysis.

STUDY OBJECTIVES: Bronchial artery embolization (BAE) has been established as an effective technique in the emergency treatment of life-threatening hemoptysis, but few data concerning long-term results and complications of the procedure are available. The aim of this study was to analyze retrospectively the experience of BAE in our center with particular emphasis on medium-term and long-term results and on morbidity. SETTING: University hospital. PATIENTS: Fifty-six patients underwent bronchial arteriography from 1986 to 1996 in our center for the management of life-threatening hemoptysis. Of them, BAE was performed in 46 patients. Their mean age was 51 years (range, 19 to 89 years). The most frequent etiologies of hemoptysis were active or inactive tuberculosis, bronchiectasis, or idiopathic hemoptysis. RESULTS: BAE resulted in an immediate cessation of hemoptysis in 43 of the initial 56 patients (77%). During the first month after BAE, four patients who died from causes other than hemoptysis or who were referred to surgery were excluded from follow-up and in the 39 remaining patients, a complete cessation of hemoptysis was observed in 32 patients. A remission was noted in 28 of the 29 patients followed up between 30 and 90 days after BAE. Long-term control of bleeding was achieved in 25 of the initial 56 patients (45%) followed up beyond 3 months after BAE (median follow-up of 13 months; range, 3 to 76 months). Overall, complications of BAE consisted of two episodes of mediastinal hematoma and three episodes of neurologic damage, two of which improved without permanent sequelae. CONCLUSION: We conclude that BAE may result in long-term as well as immediate control of life-threatening hemoptysis but that complications are not unusual.

Cholangitis associated with cholecystitis in patients with acquired immunodeficiency syndrome.

Four patients with acquired immunodeficiency syndrome developed severe abdominal pain and fever due to acute acalculous cholecystitis. In all patients, preoperative laboratory data showed elevation of alkaline phosphatase and gamma-glutamyltransferase levels. Endoscopic or intraoperative cholangiography showed signs of intrahepatic and extrahepatic cholangitis. Cholecystectomy was performed and prompt relief of symptoms was achieved in all patients; no postoperative complication was observed. One patient did not develop any recurrence during an 18-month period of follow-up; two patients died 2 and 3 months after the operation. One patient developed recurrent abdominal pain and cholestasis 4 months after the operation, with dilatation of the common bile duct and papillary stenosis due to progression of cholangitis. These observations suggest that cholangitis is frequently associated with cholecystitis in patients with the acquired immunodeficiency syndrome. Its pathogenesis is not known.