[Optical coherence tomography of bladder resection specimen]. / Tomographie par densité optique des pièces de résection des tumeurs de vessie.

INTRODUCTION: The diagnosis of bladder urothelial tumors is based on bladder resection and histological analysis of the specimen. The time to obtain the results of the histological analysis increases the treatment delay. Furthermore, the lack of muscle on the specimen forces the surgeon to practice on other procedure. Full field optical coherence tomography (FFOCT) is a recent imaging technique to analyze tissue. The aim of our study was to evaluate the feasibility and diagnostic accuracy of FFOCT to detect muscle and tumor in bladder resection specimen. PATIENTS AND METHODS: We analyzed with the FFOCT technique bladder resection specimen of 24 consecutives patients. Three readers did the blind analyze of the images, looking for the presence of muscle and tumor on each specimen. Their results were compared with histological analysis to calculate diagnostic accuracy for each reader. RESULTS: Mean sensibilities for the detection of muscle and tumor were respectively 75% and 81%. Mean specificities for the detection of muscle and tumor were respectively 78.3% and 55.3%. CONCLUSIONS: Our results suggest that the FFOCT is feasible to analyze bladder resection specimen. Sensibilities and specificities calculated are encouraging for the detection of muscle and tumor. The accuracy of this detection and early-staging tool should be validated by larger studies. LEVEL OF EVIDENCE: 3.

[Pathological findings of visible and non-visible tumors on multiparametric magnetic resonance imaging (MRI) prior to radical prostatectomy]. / Caractéristiques anatomopathologiques des tumeurs apparentes et non apparentes en IRM multiparamétrique de la prostate avant prostatectomie totale.

INTRODUCTION: As urologists are questioned about the overtreatment of localized prostate cancer, multiparametric MRI can diagnose significant prostate cancer thanks to targeted biopsies. However, some tumors cannot be detected by MRI. What are the pathological characteristics of those tumors? MATERIALS AND METHODS: We have selected 144 consecutive patients treated with radical prostatectomy for clinically localized prostate cancer diagnosed on systematic and targeted biopsies (Koelis®) according to multiparametric MRI findings. On MRI, each suspicious area was graded according to the PI-RADS score v1.0. On radical prostatectomy specimen, tumor foci with a Gleason score greater than 3+3 and/or a tumor volume greater than 0,5cm3 were considered significant. The grade-four tumoral volume was calculated by multiplying the tumoral volume by grade 4 tumoral percentage. RESULTS: Two hundred and seventy seven tumors were identified. A hundred and thirty nine were non-visible on MRI. They had a significantly lower volume (0.15cm3 versus 1.45cm3, P<0.0001) and a Gleason score significantly lower (P<0.0001) than apparent tumors. 17.3% of non-apparent tumors were significant. Moreover, the grade-four tumoral volume of significant non-apparent tumors was significantly lower than that of significant apparent tumors (0.11cm3 versus 0.66cm3, P<0.0001). CONCLUSION: Non-apparent prostate tumors on multiparametric MRI have a Gleason score, a tumor volume - and consequently - a grade 4 tumor volume significantly lower than apparent tumors. LEVEL OF PROOF: 4.

Self-assembling peptide matrix for the prevention of esophageal stricture after endoscopic resection: a randomized controlled trial in a porcine model.

Esophageal stricture formation after extensive endoscopic resection remains a major limitation of endoscopic therapy for early esophageal neoplasia. This study assessed a recently developed self-assembling peptide (SAP) matrix as a wound dressing after endoscopic resection for the prevention of esophageal stricture. Ten pigs were randomly assigned to the SAP or the control group after undergoing a 5-cm-long circumferential endoscopic submucosal dissection of the lower esophagus. Esophageal diameter on endoscopy and esophagogram, weight variation, and histological measurements of fibrosis, granulation tissue, and neoepithelium were assessed in each animal. The rate of esophageal stricture at day 14 was 40% in the SAP-treated group versus 100% in the control group (P = 0.2). Median interquartile range (IQR) esophageal diameter at day 14 was 8 mm (2.5-9) in the SAP-treated group versus 4 mm (3-4) in the control group (P = 0.13). The median (IQR) stricture indexes on esophagograms at day 14 were 0.32 (0.14-0.48) and 0.26 (0.14-0.33) in the SAP-treated and control groups, respectively (P = 0.42). Median (IQR) weight variation during the study was +0.2 (-7.4; +1.8) and -3.8 (-5.4; +0.6) in the SAP-treated and control groups, respectively (P = 0.9). Fibrosis, granulation tissue, and neoepithelium were not significantly different between the groups. The application of SAP matrix on esophageal wounds after a circumferential endoscopic submucosal dissection delayed the onset of esophageal stricture in a porcine model.

Topical hemostatic powder promotes reepithelialization and reduces scar formation after extensive esophageal mucosal resection.

The development of techniques for endoscopic resection has provided new strategies for radical conservative treatment of superficial esophageal neoplasms, even those that are circumferential, such as Barrett's neoplasia. However, it is necessary to prevent the formation of scar tissue that can be responsible for esophageal strictures following circumferential resection. Preliminary data have suggested the possible efficacy of a hemostatic powder in the promotion of wound healing. The study aims to assess the effectiveness of Hemospray (Cook Medical) in a swine model of post-endoscopic esophageal stricture. Our prospective controlled study included 21 pigs. A 6-cm circumferential submucosal dissection of the esophagus (CESD) was performed in each pig. Group 1 (n = 11) only underwent CESD and Group 2 (n = 10) had repeated Hemospray applications after CESD. Clinical, endoscopic, and radiological monitoring were performed, blood levels of four inflammatory or pro-fibrotic cytokines were assessed, and histological analysis was performed. Median esophageal diameter was greater in the group treated with Hemospray (2 mm [1-3] vs. 3 mm [2-4], P = 0.01), and the rate of symptomatic esophageal stricture was 100% and 60% in Groups 1 and 2, respectively (P = 0.09). The thicknesses of esophageal fibrosis and inflammatory cell infiltrate were significantly lower in Group 2 than in Group 1 (P = 0.002 and 0.0003, respectively). The length of the neoepithelium was greater in Group 2 than in Group 1 (P = 0.0004). Transforming growth factor-ß levels were significantly lower in Group 2 than in Group 1 (P = 0.01). The application of Hemospray after esophageal CESD reduces scar tissue formation and promotes reepithelialization, and therefore is a promising therapeutic approach in the prevention of post-endoscopic esophageal stricture.

Systematic review: the prevention of oesophageal stricture after endoscopic resection.

BACKGROUND: Extensive endoscopic resections for the treatment of early oesophageal neoplasia can result in fibro-inflammatory strictures that require repeated interventions, which significantly alter the patients' quality of life. AIMS: To review current evidence about the prevention of oesophageal strictures following endoscopic resections. METHODS: Systematic search of PubMed and Embase from inception to March 2015 using appropriate keywords. All original publications in English were included, and articles on the treatment of oesophageal stricture were excluded. RESULTS: Of the 461 hits, 62 studies were included in the analysis. Among the wound-protective strategies, polyglycolic acid sheets showed the most convincing evidence with a 37.5% stricture rate and excellent safety. Regenerative medicine, using cell sheets of autologous keratinocytes, resulted in a 25% stricture rate, although with cost and availability concerns. Among anti-proliferative treatment modalities, steroid treatment, either endoscopically injected triamcinolone in the resection wound or orally administered prednisolone, proved effective with an overall stricture rate of 13.5%, with safety concerns regarding late oesophageal perforations and infectious morbidity. Among mechanical treatment options, poorly effective and high-risk preventive balloon dilation tend to be replaced by prophylactic covered stent, with 18-28% stricture rates. CONCLUSIONS: Although oral or locally injected steroids are promising options, no currently available technique is sufficiently efficient and devoid of significant safety concerns to recommend its routine use for the prevention of strictures after extensive endoscopic resection. Improving our knowledge in the mechanisms of oesophageal wound healing will guide the development of novel methods for stricture prevention.

[Full field optical coherence tomography of prostate biopsies: a step towards pre-histological diagnosis?]. / Tomographie par cohérence optique plein champ des biopsies de la prostate: un pas vers le diagnostic pré-histologique?

OBJECTIVES: To evaluate the value of full field optical coherence tomography (FFOCT) for cancer detection on prostate biopsies PATIENTS AND METHODS: Eight consecutive patients who underwent prostate biopsies for an elevated PSA or suspicious DRE findings were included in the study. For each patient, one to three biopsy cores were imaged with FFOCT immediately after sampling. Images obtained were analyzed by a pathologist blinded to the pathological results, and classified into three categories: non-cancerous tissue, suspicion of malignancy and prostate carcinoma. A pathological correlation analysis was further performed. RESULTS: Sixteen biopsy cores were analyzed. The median FFOCT procedure time was of 4 (3-5) minutes. No artifact was noted in subsequent pathological analysis. Six cores were involved with cancer and eight cores showed no evidence of cancer. On two cores, diagnosis was uncertain, and immuno-histochemical analysis confirmed cancer involvement in one of them. The agreement rate between standard histological analysis and FFOCT evaluation was of 81% (13/16). The three cases of disagreement were due to one false positive and two false negatives of FFOCT analysis. CONCLUSIONS: FFOCT of prostate biopsy cores seemed to be feasible and to allow concordant results with those of pathological analysis in the majority of the cases.

[Severe cholestatic hepatitis revealing a DRESS syndrome]. / Hépatite cholestatique sévère révélant un Drug Rash with Eosinophilia and Systemic Symptoms (DRESS) syndrome.

INTRODUCTION: Drug Rash with Eosinophilia and Systemic Symptoms (DRESS) syndrome is a drug-induced hypersensitivity syndrome, characterized by rash, hyereosinophilia and multiorgan failure, including cytolytic hepatitis. CASE REPORT: A 75-year-old man, treated with amoxicillin/clavulanic acid, presented with jaundice and disabling pruritus associated with severe cholestatic hepatitis, related to a DRESS syndrome. Because of the persistence of cholestasis and the severity of pruritus, a treatment with corticosteroids and plasma exchanges was initiated, allowing a rapid and complete remission. CONCLUSION: Amoxicillin/clavulanic acid, although rarely described in the literature, is a rare cause of DRESS syndrome. Severe cholestatic hepatitis associated with disabling pruritus may be one of the systemic manifestations, with a good prognosis using corticosteroids and plasma exchanges.

Multiparametric MRI features of granulomatous prostatitis and tubercular prostate abscess.

The authors report the diffusion and contrast-enhanced MRI appearance of five cases of granulomatous prostatitis (GP), non-specific (two cases) and infectious post-Bacillus Calmette-Guerin (BCG) therapy (three cases, with a tubercular abscess in two of them). All patients had raising PSA levels and abnormal DRE. History of BCG therapy or acute prostatitis was present in four patients. Multiparametric MRI (T2W-MRI, DW-MRI and DCE-MRI) was performed before biopsies. Diagnosis was confirmed by TRUS-guided biopsies in four cases and by transurethral resection in one case. MRI showed a tumor-like appearance in three cases, an abscess-like appearance in one case and a combined tumor/abscess-like appearance in one case. Extraprostatic fat was infiltrated in three patients, simulating T3a disease. Histologically, caseous necrosis was found when MRI showed abcedation. Demonstration of occult tubercular abscesses in post-BCG GP may have therapeutic implications and MRI is useful prior to surgical or interventional drainage of large caseous abscesses.

[Prebiopsy multiparametric MRI of the prostate: the end of randomized biopsies?]. / IRM mutiparamétrique de la prostate avant biopsies : la fin des biopsies systématisées ?

OBJECTIVE: To evaluate the value of multiparametric MRI-targeted prostate biopsies in patients with suspected low-risk prostate cancer. PATIENTS AND METHOD: Patients with normal digital rectal examination and a PSA level between 4 and 10 ng/mL were prospectively included. A multiparametric MRI of the prostate was performed prospectively before the biopsies. 12-core randomized biopsies were performed, with additional targeted samples in each suspicious area identified on MRI. Detected cancers and their histological characteristics were compared between those two biopsy protocols. A micro focal cancer (MFC) was defined by the presence of less than 4mm of Gleason score 3+3 cancer on a single core. RESULTS: Seventy-one consecutive patients were included. The overall detection rate was of 53% (38/71). It was of 70% (26/37) in the presence of suspicious area on MRI versus 35% (12/34) in the absence of any suspicious area (P=0.004). MRI-targeted biopsies alone detected three cancers, none of which was a MFC. 12-core biopsies alone detected 14 cancers, including ten MFC (71%). In 21 patients, prostate cancer was detected by both the MRI-targeted and 12-core biopsies. The Gleason score in the MRI-targeted area was the highest Gleason score in 90% of the cases. It was high (>6) in 76% (16/21) of the patients. CONCLUSIONS: MRI-targeted biopsies detected less micro focal cancers than randomized 12-core biopsies. They did not seem however to decrease the detection of clinically significant cancers.

Imaging in lower urinary tract infections.

In epididymo-orchitis, a sonogram shows a non-homogenous and hypertrophied epididymis and testis, with increased vascularisation seen on a Doppler sonogram. Abscesses must be investigated using sonography so that a necrotic tumour is not misdiagnosed. In prostatitis, sonography is indicated to investigate urine retention and where treatment has failed (to look for a blockage, an abscess, or pyelonephritis). Endorectal sonography is the best imaging modality for analysing the parenchyma, but otherwise has limited value. Chronic prostatitis is the main differential diagnosis from prostate cancer; the two may be distinguished using diffusion MRI. In cases of cystitis, imaging is indicated when a patient has recurrent cystitis (to investigate what the causative factors might be), or an infection with a less common bacterium (to look for calcifications, emphysema, any involvement of the upper urinary tract), and in cases of cystitis with pseudotumour.

[pT3N0 prostate cancer treated with radical prostatectomy as sole treatment: Oncological results and predictive factors of recurrence]. / Cancer de la prostate de stade pT3N0 traité par prostatectomie radicale en monothérapie : résultats carcinologiques et facteurs prédictifs de récidive.

OBJECTIVES: To evaluate biological free survival in patients with locally advanced prostate cancer treated with radical prostatectomy (RP) as sole treatment, and to analyse predictive factors of recurrence. PATIENTS AND METHOD: We retrospectively studied patients treated between 1996 and 2006 for a pT3N0 prostate cancer with RP without any adjuvant treatment. The main endpoint was PSA relapse, defined as two successive elevations of PSA>0.2 ng/mL. An association between PSA free survival and PSA, Gleason score, pathological stage and surgical margins status was statistically assessed. RESULTS: A total of 147 patients were included. Median preoperative PSA was of 10 ng/mL. Pathological stage was pT3b in 30% of the cases and surgical margins showed cancer involvement in 63% of the cases. Gleason score was ≥3+4 in 74% of the cases. Postoperative PSA was undetectable in 121 (82%) patients. Median follow up following RP was of 5 years. The 5-year-PSA free survival was of 48%. Multivariate analysis showed that preoperative and postoperative PSA, as well as Gleason score were predictors of PSA relapse (P<0.05). In patients with undetectable postoperative PSA, 5-year-PSA free survival was of 56%. Seminal vesicle involvement and Gleason score ≥3+4 were the only independent predictors of PSA relapse. CONCLUSIONS: After RP for pT3N0 prostate cancer, the only predictive factors of recurrence were postoperative PSA and Gleason score. In case of undetectable postoperative PSA, surveillance seems acceptable if Gleason score is <3+4 and in the absence of seminal vesicle involvement.

Endorectal 3D T2-weighted 1mm-slice thickness MRI for prostate cancer staging at 1.5Tesla: should we reconsider the indirects signs of extracapsular extension according to the D'Amico tumor risk criteria?

PURPOSE: To evaluate the accuracy of a 3D-endorectal 1mm-thick slices MRI acquisition for local staging of low, intermediate and high D'Amico risk prostate cancer (PCa). MATERIALS AND METHODS: 178 consecutive patients underwent a multiparametric MRI protocol prior to radical prostatectomy (RP). T2W images were acquired with the 3D sampling perfection with application optimized contrasts using different flip angle evolutions (SPACE) sequence (5mn acquisition time). Direct and indirect MRI signs of extracapsular extension (ECE) were evaluated to predict the pT stage. The likelihood of SVI (seminal vesicle invasion) was also assessed. RESULTS: Histology showed ECE and SVI in 38 (21%) and 12 (7%) cases, respectively. MRI sensitivity and specificity to detect ECE were 55 and 96% if direct signs of ECE were used and 84 and 89% (p<0.05), if both direct and indirect signs were combined. D'Amico criteria did not influence MRI performance. Sensitivity and specificity for SVI detection were 83% and 99%. CONCLUSIONS: 3D data sets acquired with the SPACE sequence provides a high accuracy for local staging of prostate cancer. The use of indirect signs of ECE may be recommended in low D'Amico risk tumors to optimise patient selection for active surveillance or focal therapy.

Value of multiparametric MRI in the work-up of prostate cancer.

The role of magnetic resonance imaging (MRI) in prostate cancer evaluation is controversial and likely underestimated. Technological advances over the past 5 years have demonstrated that multiparametric MRI, including diffusion-weighted imaging (DWI) and dynamic contrast-enhanced MRI, can evaluate the actual tumor burden of a newly diagnosed prostate cancer more accurately than sextant biopsy protocols. Tumor risk, defined by the D'Amico criteria, hence can be re-evaluated by multiparametric MRI. As a result, there is increasing evidence that MRI before repeat or even initial biopsy can accurately select patients who require immediate biopsies and those in whom biopsy could be deferred. Also, a relationship between apparent diffusion coefficient (ADC), calculated from DWI, and Gleason score was found. Thus, MRI before biopsy helps to detect high-grade tumors to target biopsies within areas of low ADC values. To achieve good targeting accuracy, transrectal ultrasound (TRUS)-MRI image registration is necessary. Three-dimensional deformable registration is sufficiently accurate to match TRUS and MRI volumes with a topographic precision of 1 mm. Real-time MRI-guided biopsy is another technique under evaluation. Both approaches will allow for increasing acceptance of focal therapies, should these techniques be validated in the future.

Multiparametric MRI is helpful to predict tumor focality, stage, and size in patients diagnosed with unilateral low-risk prostate cancer.

To study the staging accuracy of multiparametric magnetic resonance imaging (MRI) in patients showing unilateral low-risk cancer on prostate biopsy. A total of 58 consecutive patients with low-risk cancer (D'Amico classification) and unilateral cancer involvement on prostate biopsies were included prospectively. All patients underwent multiparametric endorectal MRI before radical prostatectomy, including T2-weighted (T2W), diffusion-weighted (DW) and dynamic contrast enhanced (DCE) sequences. Each gland was divided in eight octants. Tumor foci >0.2 cm(3) identified on pathological analysis were matched with MRI findings. Pathological examination showed tumor foci >0.2 cm(3) in 50/58 glands (86%), and bilateral tumor (pathological stagepT2c) in 20/58 (34%). For tumor detection in the peripheral zone (PZ), T2W+DWI+DCE performed significantly better than T2W+DWI and T2W alone (P<0.001). In the transition zone (TZ), only T2W+DWI performed better than T2W alone (P=0.02). With optimal MR combinations, tumor size was correctly estimated in 77% of tumor foci involving more than one octant. Bilateral tumors were detected in 80% (16/20) of cases. In patients with unilateral low-risk prostate cancer on biopsy, multiparametric MRI can help to predict bilateral involvement. Multiparametric MRI may therefore have a prognostic value and help to determine optimal treatment in such patients.

FDG-PET improves surgical outcome in negative MRI Taylor-type focal cortical dysplasias.

OBJECTIVE: To determine the diagnostic accuracy and prognostic value of ¹8FDG-PET in a recent series of patients operated for intractable partial epilepsy associated with histologically proven Taylor-type focal cortical dysplasia (TTFCD) and negative MRI. METHODS: Of 23 consecutive patients (12 male, 7-38 years old) with negative 1.5-Tesla MRI, 10 exhibited subtle nonspecific abnormalities (e.g., unusual sulcus depth or gyral pattern) and the 13 others had strictly normal MRI. FDG-PET was analyzed both visually after coregistration on MRI and using SPM5 software. Metabolic data were compared with the epileptogenic zone (EZ) determined by stereo-EEG (SEEG) and surgical outcome. RESULTS: Visual PET analysis disclosed a focal or regional hypometabolism in 18 cases (78%) corresponding to a single gyrus (n = 9) or a larger cortical region (n = 9). PET/MRI coregistration detected a partially hypometabolic gyrus in 4 additional cases. SPM5 PET analysis (n = 18) was concordant with visual analysis in 13 cases. Location of PET abnormalities was extratemporal in all cases, involving eloquent cortex in 15 (65%). Correlations between SEEG, PET/MRI, and histologic findings (n = 20) demonstrated that single hypometabolic gyri (n = 11) corresponded to EZ and TTFCD, which was localized at the bottom of the sulcus. Larger hypometabolic areas (n = 9) also included the EZ and the dysplastic cortex but were more extensive. Following limited cortical resection (mean follow-up 4 years), seizure freedom without permanent motor deficit was obtained in 20/23 patients (87%). CONCLUSIONS: ¹8FDG-PET coregistered with MRI is highly sensitive to detect TTFCD and greatly improves diagnosis and surgical prognosis of patients with negative MRI.

[Diffusion-weighted MR imaging of the prostate]. / IRM de diffusion de la prostate.

Functional imaging complements T2-weighted imaging in the evaluation of the prostate. The most frequently used techniques are diffusion-weighted imaging and perfusion imaging following the intravenous administration of contrast material. Perfusion imaging has high sensitivity and moderate specificity, even when using a quantitative technique, because contrast kinetics in some cases of peripheral zone prostatitis and benign transition zone hyperplasia may simulate cancer. Diffusion-weighted imaging is currently under evaluation but appears to be preferable to dynamic perfusion MR imaging because of its higher specificity and simpler acquisition. Functional imaging of the prostate is performed to detect cancers missed on biopsies or evaluate the volume of a newly diagnosed clinically localized cancer to assist in therapy selection. Future applications for image-guidance of targeted therapies to the tumor are currently investigational.