Hemostastic embolization in oncology.

Several mechanisms predispose to bleeding in neoplastic disease. This is all the more serious as it often occurs on a background of medically vulnerable patients and the magnitude of the bleed may lead to hemorrhagic shock or acute respiratory distress as a result of hemoptysis. It often carries a poor prognosis, even if the acute episode has been controlled, as bleeding due to rupture of a tumor often indicates an advanced stage of the disease, and also because tumor rupture carries a risk of metastatic spread including peritoneal carcinomatosis. The risk of recurrent bleeding is also not insignificant. In most cases, endovascular hemostatic embolization is the first line palliative treatment.

[Cardiac tumors: CT and MR imaging features]. / Tumeurs cardiaques: aspects en scanner et en IRM.

The CT and MR imaging features of the main cardiac tumors will be reviewed. Cross-sectional imaging features may help differentiate between cardiac tumors and pseudotumoral lesions and identify malignant features. Based on clinical features, imaging findings are helpful to further characterize the nature of the lesion. CT and MR imaging can demonstrate the relationship of the tumor with adjacent anatomical structures and are invaluable in the presurgical work-up and postsurgical follow-up.

[Thermal ablation: tolerance and efficacy in a population mostly composed of primary lung cancers]. / Thermo-ablation pulmonaire: tolérance et efficacité thérapeutique dans une population constituée majoritairement de tumeurs primitives pulmonaires.

PURPOSE: Radiofrequency thermal ablation (TA) of lung tumors currently is considered an alternative to surgical management for early primary lung cancers and non-surgical lung metastases. The purpose of this study was to determine the tolerability and efficacy of this treatment in 29 consecutive patients, most of which with primary lung cancers, managed in our center. MATERIALS AND METHODS: Twenty-nine patients with 32 lung tumors less than 35 mm in diameter underwent radiofrequency thermal ablation between May 2004 and July 2008. The CT examinations performed during and after the ablation were reviewed to determine lesion characteristics, complications, treatment, local recurrence rate and survival rate. RESULTS: Sixty-nine percent of our population consisted of primary lung cancer. The incidence of pneumothorax was 72% with 10% requiring drainage. The rate of complete response was 81%. The survival rate at 1 year was 79%. CONCLUSION: Radiofrequency thermal ablation of lung tumors is a minimally invasive technique with high rate of complete response. It can be considered in non-surgical patients with primary or metastatic lung tumors less than 35 mm in diameter.

[Stenting for superior vena cava obstruction associated with lung cancer: monocentric study]. / Mise en place précoce d'une endoprothèse dans les syndromes de la veine cave supérieure: étude monocentrique.

INTRODUCTION: Superior vena cava obstruction is an urgent complication of lung cancer. Superior vena cava stent insertion can be considered to provide rapid relief of the symptoms. METHODS: To estimate the efficiency and the complications of this procedure, we retrospectively analyzed 41 consecutive patients treated during the last 5 years by self-expanding nitinol stent insertion for superior vena cava obstruction due to lung cancer. It was combined with anticoagulation and corticosteroids. RESULTS: 41 patients benefited from this treatment (30 men and 11 women) with an average age of 59 years. Etiologies of the vena cava obstruction were: small cell carcinoma (11), adenocarcinoma (8), squamous cell carcinoma (9), large cell carcinoma (9) and others (4). All patients were symptomatic. The average period between the onset of symptoms and the vascular stenting was 14 days. Specific treatment was chemotherapy (18 patients), radiotherapy (1 patient), or both (14 patients), and no specific treatment for 6 patients. The procedure consisted of the insertion of 1 (73%) or 2 (27%) stents, with an average length and caliber of 7.5 cm and 14 mm respectively. No major complication was reported in short and long-term follow up. Symptomatic improvement was observed for all the patients within 48 hours. Median survival after the stenting was of 6.7 months. CONCLUSION: In our study, vascular stenting for malignant superior cava vena obstruction allows a rapid improvement of the symptoms with very few complications, suggesting a possible role as first line treatment for chemo or radio-resistant tumours.

[Radiofrequency ablation of primary lung cancer: a single centre experience]. / Thermo-ablation de cancer bronchique primitif inopérable: étude monocentrique.

INTRODUCTION: Radiofrequency ablation is a new interventional radiological technique for the treatment of primary or secondary lung tumors of small size (less than 3 cm) in inoperable patients or patients unsuitable for external radiotherapy. This procedure is already used in liver and renal cancers and metastases, and is now being evaluated in primary and secondary lung tumors. METHODS: We have followed-up, by CT scanning, 12 consecutive patients with primary lung tumors treated by radiofrequency ablation in our institution between 2004 and 2008. RESULTS: Our study shows that radiofrequency ablation is well-tolerated with few minor side effects (75% pneumothorax) and no major side effects. Moreover, it gives good local control (8.3% local progression). CONCLUSIONS: Radiofrequency appears to be a valuable alternative to surgery for inoperable patients presenting with a small primary lung tumor.

[Cardiac CT: technical considerations]. / Conditions techniques d'utilisation de la tomodensitométrie à rayons X en pathologie cardiaque.

The possibility to perform cardiac and coronary imaging was a major driving force behind an ongoing, rapid evolution of scanner technology, accompanied by improvements of software and post-processing tools. The most recent generations of MDCT with the ability to acquire at least 64 slices simultaneously allow relatively robust morphological and functional imaging of the heart. By nature of its target, the continuously moving heart, cardiac CT is technically more challenging than other CT applications. Also, rapid technical development requires constant adaptation of acquisition protocols. The present manuscript summarizes the current state of technology of cardiac CT. Included are considerations regarding appropriate patient selection, patient medication, contrast enhancement, acquisition and reconstruction parameters, image display and analysis techniques with a special emphasis on radiation dose and all possible measures to keep the dose. It does not constitute a meta-analysis of published literature, but merely reflects an expert consensus on the current technical aspects of cardiac CT imaging.

[Current indications for cardiac CT]. / Les indications actuelles du scanner cardiaque.

There is a need to define the current indications for coronary CT angiography (CCTA) even as technology continuously evolves. CCTA using 64 MDCT units has shown to be highly accurate for diagnosis of stenoses >or=50% on selected populations. It is currently used for its negative predictive value (96-98%). Stenosis quantification remains inferior to conventional coronary angiography with tendency to overestimate stenoses <70%. For diagnosis of coronary artery disease, CCTA is considered based on clinical findings (pre-test probability of coronary artery disease) and presence of myocardial ischemia on other functional studies. The main appropriate indications include: In the setting of acute coronary syndrome, CCTA excludes coronary artery disease with excellent NPV and good negative likelihood ratio (0.05) when ECG is non-contributory, 2 consecutive troponin levels at 6 hours are negative in a patient with low risk of coronary artery disease. In the setting of stable angina or atypical precordial chest pain, CCTA is indicated in patient with low to medium risk when functional test are non-contributory or unavailable, or ECG is non-interpretable. CCTA is a complement to coronary angiography for morphological evaluation of some lesions prior to angioplasty and stent placement (long segment occlusion, proximal lesions involving LAD and circumflex arteries). In selected patients, CCTA may replace coronary angiography prior to valvular surgery.

The importance of imaging assessment before endovascular repair of thoracic aorta.

Indications for and experience with placement of endovascular stent grafts in the thoracic aorta are still evolving. Recent advances in imaging technologies have drastically boosted the role of pre-procedural imaging. The accepted diagnostic gold standard, digital subtraction angiography, is now being challenged by the state-of-the-art computed tomography angiography (CTA), magnetic resonance angiography (MRA) and trans-oesophageal echocardiography (TEE). Among these, technological advancements of multidetector computed tomography (MDCT) have propelled it to being the default modality used, optimising the balance between spatial and temporal resolutions and invasiveness. MDCT angiography allows the comprehensive evaluation of thoracic lesions in terms of morphological features and extent, presence of thrombus, relationship with adjacent structures and branches as well as signs of impending or acute rupture, and is routinely used in these settings. In this article, we review the current state-of-the-art radiological imaging for thoracic endovascular aneurysm repair (TEVAR), especially focusing on the role of MDCT angiography. After analysing the technical aspects for optimised imaging protocols for thoracic aortic diseases, we discuss pre-procedural determinants of candidacy, and how to formulate interventional plans based on cross-sectional imaging.

[Interventional radiology and thoraco-abdomino-pelvic trauma]. / Radiologie interventionnelle et traumatismes thoraco-abdomino-pelviens.

Multidetector CT is very useful in the evaluation of polytrauma patients. MDCT is valuable for the detection and treatment planning of vascular injuries, but it may not be available to hemodynamically unstable patients. Embolization of visceral and parietal branches of the aorta benefits from advances in catheter technology: hydrophilic catheters and microcatheters are very helpful in this context. Resorbable particles (such as gelatin) and coils are the most useful occlusive agents. Endovascular stenting of aortic rupture is nowadays considered in many centers as the best therapeutic option and can be proposed as an alternative to surgery.

[Pulmonary vein stenosis after radiofrequency ablation for atrial fibrillation]. / Sténose des veines pulmonaires après radiofréquence pour fibrillation atriale.

INTRODUCTION: Pulmonary vein stenosis is a rare condition with a high mortality. With the advent of radiofrequency ablation for atrial fibrillation a new cause of pulmonary vein stenosis has emerged. OBSERVATIONS: We report two cases of severe pulmonary vein stenosis. In the first case the diagnosis was obtained rapidly and balloon angioplasty with stent implantation was performed in the two left pulmonary veins. Recurrent occlusion occurred within the stents, extensive pulmonary infiltrates resembling pulmonary venous infarction developed and the patient died. In the second case the diagnosis was missed initially because the clinical picture suggested thrombo-embolic disease or infection. Balloon angioplasty with stent implantation was performed later. Restenosis occurred after 18 months. These two cases illustrate the frequency with which percutaneously inserted venous prostheses thombose. CONCLUSIONS: Clinicians should be familiar with the possibility of the development of pulmonary vein stenosis after radiofrequency ablation for atrial fibrillation. Pulmonary vein stenosis remains a difficult condition to manage. The pulmonary infarction should probably be considered as an urgent indication for surgical resection or even transplantation.

Evaluation of in-stent restenosis in proximal coronary arteries with multidetector computed tomography (MDCT).

The purpose of this study was to assess the ability of 16-slice computed tomography (CT) to detect in-stent restenosis of proximal coronary arteries. From November 2002 to April 2004, 134 consecutive patients with proximal stents (3.25 +/- 0.47 mm) were prospectively studied. Multidetector CT (MDCT) was performed 24 h (baseline) and 6 months after angioplasty and analysed by two radiologists blinded to the results of the coronary angiography. Sensitivity, specificity, positive and negative predictive values for in-stent restenosis were compared with conventional quantitative coronary angiography (QCA). Stenosis with a diameter >or=50% was considered diagnostic of in-stent restenosis. The CT analysis was performed in 131 and 114 patients at baseline and 6 months, respectively. The in-stent lumen was evaluable in 111 (121 stents) and 99 patients (108 stents) at baseline and 6 months, respectively. The prevalence of in-stent restenosis was 22.5%. Restenoses were correctly identified in 91.7 and 87.5% by the two radiologists. The sensitivity, specificity, positive and negative predictive values for the assessment of significant in-stent restenosis were 92, 67, 43, 97% and 87, 66, 41, 95% for the radiologists, respectively. MDCT is a potential non-invasive technique for the screening of in-stent restenosis of proximal coronary arteries that needs further improvements.

Endovascular treatment of thoracic dissection.

Type A aortic dissection remains fatal if untreated. Although classical medical therapy for type B dissection is considered the therapy of choice in uncomplicated cases, the paradigm is changing as greater experience is accrued with endovascular treatments and technical advances improve the long-term outlook. Diagnosis is also becoming more sophisticated, allowing greater appreciation of the anatomy of dissections and improving the knowledge base as their natural history is assessed.

[A rare association of double discordance with aortic arch anomalies: value of multislice CT scan]. / Association exceptionnelle d'une double discordance avec anomalie des arcs aortiques: apport du scanner multicoupe.

The authors report the case of a 14 month old infant admitted for intermittent stridor. Routine echocardiography showed atrioventricular and ventriculo-arterial discordance with an intact septum and situs solitus with levocardia. Multislice CT scan showed tracheal compression due to a Neuhauser anomaly of the aortic arches. The paucity of symptoms led to surgical abstention.

[Pleural biopsies and pleural drainage: interventional radiology]. / Biopsies pleurales et drainages pleuraux: radiologie interventionnelle.

Interventional radiography performed for diagnostic and therapeutic purposes enables specific orientation of the diagnostic and/or therapeutic interention under radiographic guidance. This minimally invasive approach reduces intervention related morbidity. Mortality remains exceptional. Pleural biopsies and pleural drainage are two interventional procedures performed as routine practices in many centers.

[Endografts (or stent-grafts) and diseases of the descending thoracic aorta]. / Endoprothèses (ou stent-grafts) et pathologies de l'aorte thoracique descendante.

The endovascular treatment of aorta diseases with S-Graft is considered as an alternative to surgery, especially interesting in patients with severe comorbidities. Indeed, the mid-term morbidity and mortality are comparable to surgery in relatively large series, and S-Graft implantation appeared as a safe, less invasive and efficient treatment for different affections of the thoracic aorta. This article reviews technical aspects, indications and results of endovascular repairs of thoracic aorta lesions. We will also assess the advantages and limitations of S-Graft therapy.

[Role of embolization in renal angiomyolipomas]. / Rôle de l'embolisation dans les angiomyolipomes du rein.

OBJECTIVE: The purpose of this study is to present the role of embolization in the treatment of renal angiomyolipoma (AML) in cases of hemorrhage and to prevent bleeding. METHODS: Over a period of 10 years, 35 AMLs in 34 patients, recruited in two medical centers, were treated with embolization: 16/35 AML were treated urgently to stop bleeding, and 19/35 AML had preventive embolization. Six patients were completely asymptomatic and 13 had a history of previous hematoma or flank pain. Catheterization was highly selective in all cases (coaxial microcatheter in 19 cases), and for embolization we used nonresorbable microparticles, coils, and alcohol. RESULTS: When patients presented with acute bleeding, embolization was efficient in 80% of cases; another embolization was necessary in two cases, and surgery in two others. In six of these cases, surgery was planned and done at a later date. When treatment was preventive, one embolization was necessary in 17 cases, and two embolizations per case were necessary in the other two. Over a period of 18 months of follow-up, we observed a 28% decrease in tumor volume; four patients were treated by surgery at a later date. CONCLUSION: Embolization is the technique of choice to treat a bleeding AML urgently. When preventive treatment is considered, in symptomatic or asymptomatic AML, embolization can be an alternative for surgery, but more data is needed to specify its proper place in the management of these tumors.

Diagnostic value of bronchoscopy, CT and transbronchial biopsies in diffuse pulmonary lymphangiomatosis: case report and review of the literature.

The authors present the case of a 48-year-old man with diffuse pulmonary lymphangiomatosis. This rare lymphatic disorder is characterized by proliferation of anastomosing lymphatic vessels varying in size. Clinical presentation and imaging findings are highly suggestive. Bronchoscopic examination of this patient showed, for the first time to our knowledge, vesicles disseminated throughout the bronchial tree. Histopathological examinations are necessary to differentiate lymphangiomatosis from lymphangiectasis. The diagnosis can be made by transbronchial biopsy without performing open lung biopsy which was, until now, considered necessary for diagnosis.

[Spiral CT scan imaging of the coronary vessels six years after complete repair of a Taussig-Bing malformation]. / Imagerie coronaire par scanner spiralé 6 ans après correction complete d'une malformation de Taussig-Bing.

The Taussig-Bing malformation is a rare form of transposition of the great arteries with a ventricular septal defect. Associated cardiac abnormalities are common: hypoplasia of the aorta and especially coronary anomalies which may complicate surgical repair. The authors report the case of a patient with this malformation diagnosed in utero and who underwent anatomical repair on the 11th day of life. The coronary anatomy described by the surgeon was type E of Yacoub and Radley-Smith's classification. The postoperative course was uncomplicated. At the age of 6, a spiral CT scan was performed routinely under betablocker therapy. The coronary trajectory with a double loop, the patency of the coronary ostia and of the aortic isthmus were accurately demonstrated by this form of imaging.