Intestinal Conventional Ultrasonography, Contrast-Enhanced Ultrasonography and Magnetic Resonance Enterography in Assessment of Crohn's Disease Activity: A Comparison with Surgical Histopathology Analysis.

BACKGROUND AND AIMS: Contrast-enhanced ultrasonography (CEUS) is a potential interesting method for assessing accurately Crohn's disease (CD) activity. We compared the value of intestinal ultrasonography (US) coupled with contrast agent injection with that of magnetic resonance enterography (MRE) in the assessment of small bowel CD activity using surgical histopathology analysis as reference. METHODS: Seventeen clinically active CD patients (14 women, mean age 33 years) requiring an ileal or ileocolonic resection were prospectively enrolled. All performed a MRE and a US coupled with contrast agent injection (CEUS) less than 8 weeks prior to surgery. Various imaging qualitative and quantitative parameters were recorded and their respective performance to detect disease activity, disease extension and presence of complications was compared to surgical histopathological analysis. RESULTS: The median wall thickness measured by US differed significantly between patients with non-severely active CD (n = 5) and those with severely active CD (n = 12) [7.0 mm, IQR (6.5-9.5) vs 10.0 mm, IQR (8.0-12.0), respectively; p = 0.03]. A non-significant trend was found with MRE with a median wall thickness in severe active CD of 10.0 mm, IQR (8.0-13.7) compared with 8.0 mm, IQR (7.5-10.5) in non-severely active CD (p = 0.07). The area under the ROC curve (AUROC) of the wall thickness assessed by US and MRE to identify patients with or without severely active CD on surgical specimens were 0.85, 95% CI (0.64-1.04), p = 0.03 and 0.80, 95% CI (0.56-1.01), p = 0.07, respectively. Among the parameters derived from the time-intensity curve during CEUS, time to peak and rise time were the two most accurate markers [AUROC = 0.88, 95% CI (0.70-1.04), p = 0.02 and 0.86, 95% CI (0.68-1.04), p = 0.03] to detect patients with severely active CD assessed on surgical specimens. CONCLUSION: The accuracy of intestinal CEUS is close to that of conventional US to detect disease activity. A thickened bowel and shortened time to peak and rise time were the most accurate to identify CD patients with severe histological disease activity.

Evaluation of a strategy using pretherapeutic fiducial marker placement to avoid missing liver metastases.

Background: Hepatic surgery is appropriate for selected patients with colorectal liver metastases (CRLM). Advances in chemotherapy have led to modification of management, particularly when metastases disappear. Treatment should address all initial CRLM sites based on pretherapeutic cross-sectional imaging. This study aimed to evaluate pretherapeutic fiducial marker placement to optimize CRLM treatment. Methods: This pilot investigation included patients with CRLM who were considered for potentially curative treatment between 2009 and 2016. According to a multidisciplinary team decision, lesions smaller than 25 mm in diameter that were more than 10 mm deep in the hepatic parenchyma and located outside the field of a planned resection were marked. Complication rates and clinicopathological data were analysed. Results: Some 76 metastases were marked in 43 patients among 217 patients with CRLM treated with curative intent. Of these, 23 marked CRLM (30 per cent), with a mean(s.d.) size of 11·0(3·4) mm, disappeared with preoperative chemotherapy. There were four complications associated with marking: two intrahepatic haematomas, one fiducial migration and one misplacement. After a median follow-up of 47·7 (range 18·1-144·9) months, no needle-track seeding was noted. Of four disappearing CRLM that were marked and resected, two presented with persistent active disease. Other missing lesions were treated with thermoablation. Conclusion: Pretherapeutic fiducial marker placement appears useful for the curative management of CRLM.

Original Study: Transjugular Intrahepatic Portosystemic Shunt as a Bridge to Abdominal Surgery in Cirrhotic Patients.

BACKGROUND: Transjugular intrahepatic portosystemic shunt (TIPS) has been suggested to reduce portal hypertension-associated complications in cirrhotic patients undergoing abdominal surgery. The aim of this study was to compare postoperative outcome in cirrhotic patients with and without specific preoperative TIPS placement, following elective extrahepatic abdominal surgery. METHODS: Patients were retrospectively included from 2005 to 2016 in four centers. Patients who underwent preoperative TIPS (n = 66) were compared to cirrhotic control patients without TIPS (n = 68). Postoperative outcome was analyzed using propensity score with inverse probability of treatment weighting analysis. RESULTS: Overall, colorectal surgery accounted for 54% of all surgical procedure. TIPS patients had a higher initial Child-Pugh score (6[5-12] vs. 6[5-9], p = 0.043) and received more beta-blockers (65% vs. 22%, p < 0.001). In TIPS group, 56 (85%) patients managed to undergo planned surgery. Preoperative TIPS was associated with less postoperative ascites (hazard ratio = 0.330 [0.140-0.780]). Severe postoperative complications (Clavien-Dindo > 2) and 90-day mortality were similar between TIPS and no-TIPS groups (18% vs. 23%, p = 0.392, and 7.5% vs. 7.8%, p = 0.644, respectively). CONCLUSIONS: Preoperative TIPS placement yielded an 85% operability rate with satisfying postoperative outcomes. No significant differences were found between TIPS and no-TIPS groups in terms of severe postoperative complications and mortality, although TIPS patients probably had worse initial portal hypertension.

Evaluation of the peritoneal carcinomatosis index with CT and MRI.

BACKGROUND: The aim was to determine the incremental value of MRI compared with CT in the preoperative estimation of the peritoneal carcinomatosis index (PCI). METHODS: CT and MRI examinations of patients with peritoneal carcinomatosis were evaluated. CT images were first analysed by two observers who determined a first PCI (PCICT ). Then, the two observers reviewed MRI examinations in combination with CT and determined a second PCI (PCICT+MRI ). The sensitivity and negative predictive value of the two imaging sets were determined using surgery as a reference standard (PCIRef ). RESULTS: CT plus MRI was more accurate in predicting the surgical PCI than CT alone. The absolute difference between PCICT+MRI and PCIRef was lower than that between PCICT and PCIRef (mean(s.d.) 3·96(4·10) versus 4·89(4·73); P = 0·010). The number of true-positive findings increased from 106 to 125 for reader 1 and from 117 to 132 for reader 2 with the adjunct of MRI. For both readers, an increased sensitivity was obtained when both MRI and CT were used (from 63 to 81 per cent for reader 1; from 44 to 81 per cent for reader 2). The increase in sensitivity was greater for patients with a moderate volume of disease. CONCLUSION: The combination of CT and MRI improved the preoperative estimation of PCI compared with CT alone.

Locally advanced pancreatic duct adenocarcinoma: pancreatectomy with planned arterial resection based on axial arterial encasement.

Pancreatectomy with arterial resection for locally advanced pancreatic duct adenocarcinoma (PDA) is associated with high morbidity and is thus considered as a contraindication. The aim of our study was to report our experience of pancreatectomy with planned arterial resection for locally advanced PDA based on specific selection criteria. MATERIAL AND METHODS: All patients receiving pancreatectomy for PDA between October 2008 and July 2014 were reviewed. The patients were classified into group 1, pancreatectomy without vascular resection (66 patients); group 2, pancreatectomy with isolated venous resection (31 patients), and group 3, pancreatectomy with arterial resection for locally advanced PDA (14 patients). The primary selection criteria for arterial resection was the possibility of achieving a complete resection based on the extent of axial encasement, the absence of tumor invasion at the origin of celiac trunk (CT) and superior mesenteric artery (SMA), and a free distal arterial segment allowing reconstruction. Patient outcomes and survival were analyzed. RESULTS: Six SMA, two CT, four common hepatic artery, and two replaced right hepatic artery resections were undertaken. The preferred arterial reconstruction was splenic artery transposition. Group 3 had a higher preoperative weight loss, a longer operative time, and a higher incidence of intraoperative blood transfusion. Ninety-day mortality occurred in three patients in groups 1 and 2. There were no statistically significant differences in the incidence, grade, and type of complications in the three groups. Postoperative pancreatic fistula and postpancreatectomy hemorrhage were also comparable. In group 3, none had arterial wall invasion and nine patients had recurrence (seven metastatic and two loco-regional). Survival and disease-free survival were comparable between groups. CONCLUSION: Planned arterial resection for PDA can be performed safely with a good outcome in highly selected patients. Key elements for defining the resectability is based on the extent of the axial arterial encasement with two criteria: the origin of the CT and SMA are free from tumor invasion and the possibility of distal reconstruction.

[Cryotherapy percutaneous for renal tumors: Our center's beginning experience]. / Cryothérapie pour les tumeurs rénales: le début d'expérience de notre centre.

OBJECTIVE: To evaluate oncologic and functional outcomes after percutaneous cryoablation (PCA) for renal masses based on our single center experience. PATIENTS AND METHODS: We retrospectively identified 26 patients who underwent PCA for 28 tumors between November 2006 and June 2011. Patient's demographics and baseline clinical characteristics, tumor features, perioperative information, and postoperative outcomes we rerecorded. A biopsy was performed systematically before each procedure. Control imaging was obtained at 1, 3, 6 and 12 months, and yearly thereafter. Oncological outcomes were determined by radiographic evidence of tumor recurrence, which was defined by contrast enhancement at the cryoablation site on control imaging at M3. RESULTS: Patients had mean age of 70.1 years, mean Charlson comorbidity index (CCI) and body mass index) were 6 and 29 kg/m(2) respectively. There were 11 kidney transplants, including 4 solitary. Mean tumor size was 29.5mm and was represented mainly by clear cell renal cell carcinomas (16/28), endophytic (17/28) and midkidney (14/28) (±9.8). Twenty-five cryoablations were performed percutaneously by two lumbotomy. Mean clearance preoperative MDRD was 66,1 mL/min. Mean length of stay was 3.3 days (±2.2). Intraoperative complications consisted of 2 pneumothorax and 6 minor complications postoperative (Clavien≤2). There were no major complications. Mean follow-up was 27.5 months (±15.7), MDRD clearance distance was 61.9 mL/min. Overall survival and disease-specific survival was 100%, while the recurrence-free survival was 78.6% (5 recurrences and 1 failure treatment). CONCLUSION: The percutaneous cryoablation provides a safe and oncologically to extirpative surgery for renal masses in patients with significant medical comorbidities. LEVEL OF EVIDENCE: 5.

A new internet tool to report peritoneal malignancy extent. PeRitOneal MalIgnancy Stage Evaluation (PROMISE) application.

Based on the importance of assessing the true extent of peritoneal disease, PeRitOneal MalIgnancy Stage Evaluation (PROMISE) internet application (www.e-promise.org) has been developed to facilitate tabulation and automatically calculate surgically validated peritoneal cancer index (PCI), and other surgically validated scores as Gilly score, simplified peritoneal cancer index (SPCI), Fagotti and Fagotti-modified scores. This application offers computer-assistance to produce simple, quick but precise and standardized pre, intra and postoperative reports of the extent of peritoneal metastases and may help specialized and non-specialized institutions in their current practice but also facilitate research and multicentre studies on peritoneal surface malignancies.

Preoperative CT and MRI prediction of non-resectability in patients treated for pseudomyxoma peritonei from mucinous appendiceal neoplasms.

AIMS: To evaluate computed tomography (CT) and magnetic resonance imaging (MRI) findings for sign of hepatoduodenal ligament and small bowel non-resectability in patients with pseudomyxoma peritonei (PMP) and to compare assessments made by the radiologist based on their experiences. METHODS: Between January 2009 and June 2014, all consecutive patients with PMP selected for curative surgery were scheduled to undergo CT and MRI examinations within two days of their surgery. Several imaging findings of hepatoduodenal ligament and small bowel involvements were retrospectively evaluated by a senior and a junior radiologist and compared with surgical findings. RESULTS: Of the 82 patients enrolled in the study, 11 had non-resectable lesions with hepatoduodenal ligament infiltration (n = 4) and/or extensive small bowel involvement (n = 9). All patients underwent CT and 73 underwent MRI scan. Infiltration of the adipose tissue of the hepatoduodenal ligament by mucinous tumor was associated with non-resectability. For the senior and junior radiologists, the sensitivity and specificity were 75% and 100%, and 50% and 100% on CT (kappa value (k) = 0.79); 67% and 100%, and 33% and 97% on MRI (k = 0.38), respectively. Diffuse involvement of the mesentery and/or the small bowel serosa was also associated with non-resectability. For the senior and junior radiologists, the sensitivity and specificity were 67% and 100%, and 56% and 99% on CT (k = 0.82); 88% and 100%, and 38% and 100% on MRI (k = 0.58), respectively. CONCLUSION: CT and MRI can both contribute to the diagnosis of non-resectability in patients with PMP. The use of MRI to identify small bowel involvement, in particular, benefits from a more experienced radiologist.

Arterial splanchnic aneurysms: Presentation, treatment and outcome in 112 patients.

PURPOSE: The purpose of this study was to identify subgroups with different risks of progression and their appropriate management among the heterogeneous group of 112 patients diagnosed with splanchnic aneurysm. METHODS: Using radiology databases and medical records of our institution (Hospital Édouard-Hérriot, Lyon, France), we undertook a retrospective review of all patients diagnosed with splanchnic artery aneurysms from 1995 to 2011. Cases were analyzed by aneurysm location, etiology and a distinction was also made between true and false aneurysms. RESULTS: False aneurysms were more likely than true aneurysms to be diagnosed as symptomatic and/or ruptured (TA: 50/66 patients asymptomatic vs. FA: 16/46 asymptomatic, P<0.05) with a rupture rate of 59% (27/46) which was unrelated to the size of aneurysms. Percutaneous treatment was carried in the majority of patients with a final success rate of 91%. Peripancreatic true aneurysms were associated in 75% of cases with celiac occlusive disease and diagnosed mostly in symptomatic patients (7/9: 78%) with a rupture rate of 44% unrelated to their size. Radiologic treatment has faced problems due to failure of catheterization and incomplete embolization, although there have been cases in which delayed occlusion was achieved. Common true aneurysms were incidental findings in 87% (57/66) of patients with 3 ruptured aneurysms which were larger than 2 cm. Observation in that group was safe: significant growth was seen only in one patient and the embolization required was successful. Splanchnic false aneurysms and peripancreatic true aneurysms carried a high and an unpredictable risk of rupture that warranted prompt endovascular treatment as soon as possible. CONCLUSIONS: Stratification by localization and by the true or false appearance of the aneurysm was an effective (means of identifying) way to identify subgroups with different risks of progression. False aneurysms and peripancreatic true aneurysms carried a high and unpredictable risk of rupture. The splanchnic aneurysms should have been treated in the case of patients of childbearing age, size ≥ 20 mm, and in the case of liver transplantation. Other splanchnic aneurysms should either have been observed, if smaller than 2 cm. In the absence of rigorous published comparisons, surgical and endovascular methods should have been considered equally suitable in the elective treatment of these patients.

Feasibility of Catheter Placement Under Ultrasound Guidance for Progressive Preoperative Pneumoperitoneum for Large Incisional Hernia with Loss of Domain.

INTRODUCTION: Large incisional hernias with loss of domain (LIHLD) of the abdominal wall remain a therapeutic challenge due to the difficulty of replacing the contents of the hernia sac into the peritoneal cavity. Preoperative progressive pneumoperitoneum (PPP) is a valuable option. The purpose of this study was to evaluate the feasibility of peritoneal catheter insertion under ultrasound guidance for PPP and to compare the morbidity and mortality of this new technique to previously used techniques in our department. METHODS: Medical records were reviewed retrospectively from February 1989 to April 2013 in a single institution. Three different techniques of PPP were evaluated: surgical subcutaneous implantable port (SIP), surgical peritoneal dialysis catheter (PDC), and radiologic multipurpose drainage catheter (MDC). Collected data included patients' age, sex, body mass index, medical and surgical history, hernia location, PPP technique, length of hospitalization, volume of air injected, morbidity and mortality linked to PPP, and the procedure of hernia repair. RESULTS: Thirty-seven patients with a mean age of 63.1 years were evaluated. Progressive preoperative pneumoperitoneum was performed using SIP, PDC, and MDC for 14, 11, and 12 patients, respectively. Overall morbidity related to the technique was seen in 36 % of SIP, 27 % of PDC, and 0 % of MDC. One patient from the SIP group died on the 3rd postoperative day due to septic shock following aspiration pneumonia. No postoperative mortality in the other groups was observed. CONCLUSION: The MDC is an interesting modification of the original technique and is a safe procedure. It is a minimally invasive technique with a very low risk of perforation of the viscera. Therefore, the use of a non-absorbable prosthesis with MDC technique can be offered for all patients undergoing PPP without increasing the risk of infection.

Pancreatic resection in elderly patients: should it be denied?

BACKGROUND: Surgery remains the only potential curative therapy for pancreatic cancer, but compromised physiological reserve and comorbidities may deny pancreatic resection from elderly patients. METHODS: The medical records of all patients who underwent pancreatic resection at our institution (2005-2012) were retrospectively reviewed. Postoperative and long-term outcomes were compared between patients with cutoff age of 70 years. RESULTS: A total of 228 (66 %) and 116 (34 %) patients were <70 and ≥70 years, respectively. Elderly group had worse ASA scores (P < 0.0001) with higher rates of invasive malignant pathologies (75 vs. 67 %, P = 0.14), mainly pancreatic ductal adenocarcinoma (58.6 vs. 44.7 %, P = 0.01). The most common type of resection was pancreaticoduodenectomy (PD) (59 %), followed by distal pancreatectomy (19.8 %). Mean hospital stay was comparable. Elderly patients had less grade ≥IIIb postoperative complications (12 vs. 20.1 %; P = 0.04) and higher postoperative mortality rates (12.9 vs. 3.9 %; P = 0.04). In multivariable Cox proportional hazards model for postoperative mortality, age ≥ 70 years (HR, 3.5; 95 % CI, 1.3-9.3), pancreaticoduodenectomy (HR, 12.6; 95 % CI, 1.6-96), and intraoperative blood loss were significant (P = 0.012; P = 0.015, and P = 0.005, respectively). The overall 5-year survival rates for all patients, for patients aged <70 and ≥70 years were 56, 55, and 41 %, respectively (P = 0.003). CONCLUSIONS: Elderly patients are at higher risk of mortality after pancreatic resection than usually reported case series. Nonetheless, elderly patients can undergo pancreatic resection with acceptable 5-year survival results. Our results contribute for a better, informed decision-making for elderly patients and their family.

PET-CT and diagnostic CT: the synergy of metabolic and morphological data in onco-haematology.

PURPOSE: Our goal was to determine how interpreting diagnostic CT together with PET-CT could improve the assessment of morphology in onco-haematology. PATIENTS AND METHODS: Fifty-nine patients with aggressive lymphoma were retrospectively included. The diagnostic CT scan was interpreted by two radiologists, followed by a combined analysis of the CT and the PET-CT carried out by two specialists in metabolic and morphological imaging. The diagnostic performances were assessed in terms of sensitivity and specificity, then concordance and discordance rates (kappa) were studied. RESULTS: A combined interpretation of CT and PET-CT showed better diagnostic performances than those of interpretations of CT only in the assessment of nodal sites (826 sites, sensitivity of 99% versus 85%, P<0.05), extranodal sites (649 sites, sensitivity of 88% versus 78%) and bone sites (one analysed per patient, sensitivity of 50% versus 27%). The combined interpretation also improved inter-observer agreement and led to an upgraded Ann Arbor staging in 15% of patients, with a change of treatment in 10%. CONCLUSION: Interpretation of diagnostic CT in onco-haematology can be improved by combining it with an assessment of PET-CT. The synergy between metabolic and morphological information leads to improved diagnostic capabilities and renders interpretations more reproducible.

Management of respiratory motion in extracorporeal high-intensity focused ultrasound treatment in upper abdominal organs: current status and perspectives.

Extracorporeal high-intensity focused ultrasound (HIFU) is a minimally invasive therapy considered with increased interest for the ablation of small tumors in deeply located organs while sparing surrounding critical tissues. A multitude of preclinical and clinical studies have showed the feasibility of the method; however, concurrently they showed several obstacles, among which the management of respiratory motion of abdominal organs is at the forefront. The aim of this review is to describe the different methods that have been proposed for managing respiratory motion and to identify their advantages and weaknesses. First, we specify the characteristics of respiratory motion for the liver, kidneys, and pancreas and the problems it causes during HIFU planning, treatment, and monitoring. Second, we make an inventory of the preclinical and clinical approaches used to overcome the problem of organ motion. Third, we analyze their respective benefits and drawbacks to identify the remaining physical, technological, and clinical challenges. We thereby consider the outlook of motion compensation techniques and those that would be the most suitable for clinical use, particularly under magnetic resonance thermometry monitoring.

Ultrasonography and MRI features of the Mayer-Rokitansky-Küster-Hauser syndrome.

Although Mayer-Rokitansky-Küster-Hauser syndrome is a rare condition with a reported incidence of 1/4500 female live births, it represents the second most common cause of primary amenorrhea and has psychologically devastating consequences. The radiologist plays a pivotal role in both making the accurate initial diagnosis of this condition and assessing findings that may contribute to treatment planning. The purpose of this article is to provide an overview of the capabilities of ultrasound and magnetic resonance imaging (MRI) for the diagnosis and management of this syndrome with emphasis on the relevant clinical and surgical findings and to describe potential associated abnormalities and differential diagnosis.

Pathologies of the male breast.

The majority of breast lesions in men are benign. Gynaecomastia is a very common condition in which hormonal changes cause male breasts to enlarge. Three radiological patterns of gynaecomastia have been described: nodular, dendritic, and diffuse glandular pattern. The main differential diagnosis is lipomastia, which is when adipose tissue deposits are found in the subcutaneous tissue. Male breast cancer is rare. The main risk factors are pathologies that cause hormonal imbalances, a history of chest irradiation, and a family history of breast cancer (particularly in families carrying a mutation of the gene BRCA2). Mammography usually shows a mass with no calcifications. Sonography is useful to investigate local disease spread, and for detecting any enlarged axillary lymph nodes. MRI is not currently indicated to investigate male breast cancer. Very often, the clinical examination alone is enough to distinguish benign lesions from malignant lesions. Imaging must not be automatically carried out, but rather it should be used when the diagnosis is clinically uncertain or when patients present risk factors for breast cancer, as well as for guiding biopsies and for assessing disease spread.

Can mammographic assessments lead to consider density as a risk factor for breast cancer?

Admitting that mammographic breast density is an important independent risk factor for breast cancer in the general population, has a crucial economical health care impact, since it might lead to increasing screening frequency or reinforcing additional modalities. Thus, the impact of density as a risk factor has to be carefully investigated and might be debated. Some authors suggested that high density would be either a weak factor or confused with a masking effect. Others concluded that most of the studies have methodological biases in basic physics to quantify percentage of breast density, as well as in mammographic acquisition parameters. The purpose of this review is to evaluate mammographic procedures and density assessments in published studies regarding density as a breast cancer risk. No standardization was found in breast density assessments and compared density categories. High density definitions varied widely from 25 to 75% of dense tissues on mammograms. Some studies showed an insufficient follow-up to reveal masking effect related to mammographic false negatives. Evaluating breast density impact needs thorough studies with consensual mammographic procedures, methods of density measurement, breast density classification as well as a standardized definition of high breast density. Digital mammography, more effective in dense breasts, should help to re-evaluate the issue of density as a risk factor for breast cancer.

[Spontaneous hemoperitoneum during pregnancy and uterine artery aneurysm]. / Hémoperitoine spontané pendant la grossesse et anévrysme de l'artère utérine.

Spontaneous hemoperitoneum is not frequent. We report here a rare cause of spontaneous hemoperitoneum during the second trimester of pregnancy. A ruptured uterine artery aneurysm was revealed in a patient who came for important abdominal pain. A CT scan showed a large hemoperitoneum and an additional arterial image. The patient underwent rapidly an embolization, which allowed a complete closure of the aneurysm. The patient gave birth to a healthy child. The diagnosis of hemoperitoneum must be discussed without delay. Once imagery realised, a good management of the patient must be done depending on the origin of the hemoperitoneum.