Immune checkpoint inhibitor treatment of a first cancer is associated with a decreased incidence of second primary cancer.

BACKGROUND: Second primary cancers (SPCs) are diagnosed in over 5% of patients after a first primary cancer (FPC). We explore here the impact of immune checkpoint inhibitors (ICIs) given for an FPC on the risk of SPC in different age groups, cancer types and treatments. PATIENTS AND METHODS: The files of the 46 829 patients diagnosed with an FPC in the Centre Léon Bérard from 2013 to 2018 were analyzed. Structured data were extracted and electronic patient records were screened using a natural language processing tool, with validation using manual screening of 2818 files of patients. Univariate and multivariate analyses of the incidence of SPC according to patient characteristics and treatment were conducted. RESULTS: Among the 46 829 patients, 1830 (3.9%) had a diagnosis of SPC with a median interval of 11.1 months (range 0-78 months); 18 128 (38.7%) received cytotoxic chemotherapy (CC) and 1163 (2.5%) received ICIs for the treatment of the FPC in this period. SPCs were observed in 7/1163 (0.6%) patients who had received ICIs for their FPC versus 437/16 997 (2.6%) patients receiving CC and no ICIs for the FPC versus 1386/28 669 (4.8%) for patients receiving neither CC nor ICIs for the FPC. This reduction was observed at all ages and for all histotypes analyzed. Treatment with ICIs and/or CC for the FPC are associated with a reduced risk of SPC in multivariate analysis. CONCLUSION: Immunotherapy with ICIs alone and in combination with CC was found to be associated with a reduced incidence of SPC for all ages and cancer types.

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.

Thrombocytopenia due to hypersplenism in oncological disease: partial splenic embolization during palliative treatment.

Hypersplenism is excess activity of the spleen, resulting in peripheral pancytopenia that predominates in platelet cell lines. Pancytopenia can be limited by reducing the volume of the functional spleen. However, in patients in very poor general condition, a splenectomy may not be possible, due to the risks of surgery and postoperative infection. Another therapeutic alternative in these patients is to reduce the volume of the spleen by super selective percutaneous splenic embolization. We report three cases of peripheral thrombocytopenia due to hypersplenism with a platelet count between 60,000 and 80,000/mm(3), which made it impossible to continue or start a chemotherapy protocol in these patients. For these patients, super selective partial embolization of the splenic parenchyma, with uncharged microspheres (250 microns) quickly resulted in a platelet count above 150,000/mm(3) so that chemotherapy could be continued or initiated.

CT colonography: Why? When? How?

Although optical colonoscopy is still the gold standard for diseases of the colon, radiologic examination of the colon is now being performed by CT scan. Evaluation of the colon is enhanced by distension, which "de-folds" the intestinal wall, thus facilitating its examination for abnormalities of the mucosa, the wall as a whole, and the diameter of the bowel lumen. Water or gas (CO(2)) may be used for the distension, depending on the suspected lesions. The water enema method of colonography combines filling the bowel lumen with water and intravenous injection of a contrast medium. It is indicated when there is a clinical suspicion of colon cancer, or for initial discovery of liver metastases, and for staging of colon tumors. This technique, which requires little or no colon cleansing preparation, can be performed with no special equipment and has a short learning curve. The gas enema method of colonography, or virtual colonoscopy, is performed by distending the colon with CO(2), without any intravenous injection of contrast medium. Its purpose is to detect polyps as part of a screening for precancerous growths. This technique, which does require bowel cleansing preparation, uses a dedicated console for reading and requires specific training.

Transcatheter local thrombolysis in patients with extensive TIPS thrombosis.

BACKGROUND: Transcatheter local thrombolytic therapy in patients with portosplanchnic venous thrombosis has been used in few cases. CASE REPORTS: Here, we present our single-center experience with transcatheter thrombolytic therapy in three patients with extensive refractory portal and transjugular intrahepatic portosystemic shunt (TIPS) thrombosis. Thrombolytic therapy was successful for all three patients. Two patients developed minor procedure-related bleeding. CONCLUSION: Local thrombolysis could be proposed in case of TIPS thrombosis for patients in whom the venous flow cannot be restored by using conventional anticoagulant therapy and stent mechanical revision.

Small-bowel capsule endoscopy diagnoses early and advanced neoplasms in asymptomatic patients with Lynch syndrome.

BACKGROUND AND STUDY AIMS: Patients with Lynch syndrome are at increased risk of developing small-bowel adenocarcinoma, which usually has a bad prognosis and needs to be diagnosed early. Our aim was to evaluate the yield of capsule endoscopy and CT enteroclysis in this situation. PATIENTS AND METHODS: We performed a prospective, blinded, comparative study of capsule endoscopy and CT enteroclysis in five academic centers. Thirty-five consecutive asymptomatic patients with Lynch syndrome, all with one proven deleterious mutation, were included. A double reading was performed blind for both types of examination. RESULTS: Histologically confirmed small-bowel neoplasms were diagnosed in three patients (8.6 %): one adenocarcinoma (T3N0M0) and two adenomas with low-grade dysplasia. Capsule endoscopy identified all neoplasms. CT enteroclysis raised suspicion of one neoplasm (adenocarcinoma) but missed the two others. Concordance between the two capsule readings was high with a κ value of 0.78 (95 %CI 0.55 to 1.0), which was not the case for CT enteroclysis, where the κ value was 0.15 (95 %CI -0.27 to 0.58). CONCLUSION: Curable early or advanced neoplasms in asymptomatic patients with Lynch syndrome using capsule endoscopy can be detected with a better reproducibility than with CT enteroclysis. The clinical usefulness of systematic small-bowel screening in these patients should be confirmed through large prospective studies.

[Acute lower gastrointestinal bleeding: role of imaging]. / Hémorragies digestives basses aiguës: intérêt de l'imagerie.

Acute lower gastrointestinal bleeding is a frequent cause of hospital admission. Their management is complex and typically requires a multidisciplinary approach. The imaging techniques are variable. Because of the rapid image acquisition, excellent spatial resolution and multiplanar reformatting capabilities, multidetector-row CT is the imaging modality of choice in these patients. The authors will review the different types of imaging work-up and management of patients with acute lower gastrointestinal bleeding.

Pain as the only consistent sign of acute appendicitis: lack of inflammatory signs does not exclude the diagnosis.

BACKGROUND: The clinical diagnosis of acute appendicitis in adults remains tricky, but radiological examinations are very helpful to determine the diagnosis even when the adult patient presents atypically. This study was designed to quantify the proportion of patients with a preoperative diagnosis of acute appendicitis that had isolated right lower quadrant pain without biological inflammatory signs and then to determine which imaging examination led to the determination of the diagnosis. METHODS: In this monocentric study based on retrospectively collected data, we analyzed a series of 326 patients with a preoperative diagnosis of acute appendicitis and isolated those who were afebrile and had isolated right lower quadrant pain and normal white blood cell counts and C-reactive protein levels. We determined whether the systematic ultrasonography examination was informative enough or a complementary intravenous contrast media computed tomography scan was necessary to determine the diagnosis, and whether the final pathological diagnosis fit the preoperative one. RESULTS: A total of 15.6% of the patients with a preoperative diagnosis of acute appendicitis had isolated rebound tenderness in the right lower quadrant, i.e., they were afebrile and their white blood cell counts and C-reactive protein levels were normal. In 96.1% of the cases, the ultrasonography examination, sometimes complemented by an intravenous contrasted computed tomography scan if the ultrasonography result was equivocal, fit the histopathological diagnosis of acute appendicitis. CONCLUSIONS: The diagnosis of acute appendicitis cannot be excluded when an adult patient presents with isolated rebound tenderness in the right lower quadrant even without fever and biological inflammatory signs. In our study, ultrasonography and computed tomography were very helpful when making the final diagnosis.

[Pelvic trauma: impact of iodinated contrast material extravasation at MDCT on patient management]. / Traumatisme pelvien: impact de l'extravasation du produit de contraste iodé au scanner multidétecteur dans la prise en charge thérapeutique.

PURPOSE: To determine the impact of iodinated contrast material extravasation at MDCT in selecting patients with pelvic fractures that require vascular embolization. PATIENTS AND METHODS: All patients with severe pelvic fracture admitted to the trauma unit between 1998 and 2004 underwent contrast enhanced MDCT prior to additional specific treatment. All patients with extravasation underwent immediate vascular embolization for hemodynamic stabilization. Orthopedic management was proposed when no contrast extravasation was demonstrated. The presence or absence of contrast extravasation on MDCT and the hemodynamic status of the patients were recorded. RESULTS: Seventy-four patients with pelvic fracture (mean age: 34 years) underwent contrast enhanced MDCT prior to therapeutic management. Vascular embolization was performed in 42 patients: 38 showed contrast extravasation and 4 were in hemodynamic shock but showed no extravasation. Orthopedic management was performed in 27 patients after negative MDCT and 5 hemodynamically stable patients with positive MDCT. CONCLUSION: In our patient population, the presence of iodinated contrast material extravasation at MDCT was a determinant factor in the selection of patients for vascular embolization.

Hereditary-hemorrhagic telangiectasia: one-step magnetic resonance examination in evaluation of liver involvement.

PURPOSE: To describe the magnetic resonance imaging (MRI) features of hepatic involvement in hereditary-hemorrhagic telangiectasia (HHT) and to determine the interobserver agreement for all of them. PATIENTS AND METHODS: Twenty-three consecutive patients (including 17 women, mean age: 55 years) with HHT, according to the Curaçao criteria, underwent prospective MRI of the liver, including parenchymal, angiographic and biliary sequences, in one step. The scans were analyzed to determine the presence of vascular, biliary and parenchymal abnormalities (Mann-Whitney U test, kappa). The diameters of the hepatic vessels in the 23 patients were compared with those of 23 subjects with no signs of HHT or vascular or liver disease. RESULTS: MRI of the liver was abnormal in 21 patients with suspected HHT (91%). Vascular abnormalities were found in 21 patients (91%), consisting of marked dilatation of the hepatic artery (N=14), intrahepatic telangiectases (N=21), arteriosystemic venous shunting (N=19), arterioportal shunting (N=11) and aneurysms of the hepatic artery (N=3). Regenerative nodular hyperplasia was identified in 17 patients (74%) and ischemic cholangitis in nine (39%). No such lesions were found in the controls. The diameter of the hepatic artery proper was greater in patients with HHT than in the controls: 8.69+/-1.63 mm versus 5.17+/-0.44 mm, respectively (P<0.05). Good interobserver agreement was found with parenchymal and vascular abnormalities (0.62) and moderate interobserver agreement (0.42) with biliary abnormalities. CONCLUSION: One-step MRI of the liver appears to be an excellent tool for the evaluation of liver involvement in HHT, revealing vascular abnormalities, telangiectases, arteriovenous shunting, focal-liver lesions and ischemic cholangitis.

[Early embolization in the non-operative management of blunt splenic injuries: a retrospective multicenter study]. / L'embolisation précoce dans le traitement non opératoire des traumatismes fermés de la rate. Etude rétrospective multicentrique.

AIM OF THE STUDY: Splenic artery embolization has been used as an adjunct to the non-surgical management of blunt splenic injury. No consensus on its indications has emerged from the literature. This multicentric study aimed to evaluate the results of this technique in France. PATIENTS AND METHODS: Between March 2000 and April 2006, 22 patients older than 15 years of age (mean age 29, range: 15-59) with splenicv rupture due to blunt trauma underwent splenic artery embolization in six Level I Trauma Centers in France. Splenic rupture was classified Moore II in 3 cases, Moore III in 12 cases, and Moore IV in 7 cases. Angiography was performed within 4 hours of admission in half of the cases. The main indications for splenic artery embolization were: extravasation of contrast medium on CT scan (10 cases, 45%); early pseudo-aneurysm (6 cases, 23%); hypotension despite fluid resuscitation and/or progressive need for transfusion (5 cases, 22%). RESULTS: There was no mortality. Nine patients experienced complications (41%) including 6 (27%) who developed left pleural effusion. Two patients eventually underwent splenectomy (one for persistent hemorrhage, one for splenic necrosis). The overall splenic salvage rate was 91%. CONCLUSION: Splenic artery embolization is a valuable techniche that hels to lower the rate of splenectomy for traumatic splenic rupture with relatively low morbidity.

[Bile duct involvement in autoimmune pancreatitis: classification and treatment]. / Atteinte biliaire au cours d'une pancréatite auto-immune: quel cadre nosologique et quel traitement?

Autoimmune pancreatitis is a rare disease characterized by inflammation of the pancreatic parenchyma, irregular narrowing of the pancreatic duct, periductal lymphoplasmacytic infiltration and fibrosis at histological examination, the presence of autoantibodies and hypergammaglobulinemia, as well as the possible association of cholangitis and other autoimmune diseases. There is a favorable response to steroid therapy. We report the case of a patient with autoimmune pancreatitis with bile duct involvement and peripheral eosinophilia, requiring long-term immunosuppressant treatment. The diagnosis of a diffuse form of AIP was made without direct histological evidence and based on indirect imaging, clinical and laboratory findings in an autoimmune context. The histological and imaging studies of bile duct involvement and the favourable response to steroids were additional arguments.