Acquired generalized lipodystrophy under immune checkpoint inhibition.

Immune checkpoint inhibitors are now the standard of care in the treatment of several types of cancer. Cutaneous immune-related adverse events (irAEs) are usually of low grade and reversible, while endocrine irAEs are generally irreversible and managed with hormone replacement therapy. We report a 47-year-old patient, treated with the anti-programmed cell death (PD)1 antibody pembrolizumab for a metastatic melanoma, who developed severe lipodystrophy after 10 months of treatment, characterized by the loss of subcutaneous fat tissue, central obesity and insulin resistance with a decreased leptin level. Histological analysis of a cutaneous biopsy revealed subcutaneous fat cell destruction associated with oedema, the presence of lipophages, and a CD3+ lymphocytic infiltrate involving the panniculus. This led to the diagnosis of anti-PD-1-induced acquired generalized lipodystrophy, after ruling out differential diagnoses (i.e. genetic and systemic autoimmune diseases). No corticosteroids were introduced considering the high risk of inducing severe metabolic complications, and pembrolizumab was discontinued as complete response of the melanoma was achieved. However, after 12 months of follow-up, lipodystrophy and its severe metabolic complications are still ongoing. What's already known about this topic? Anti-programmed cell death (PD)1 agents are now a standard of care in the treatment of several cancers, including melanoma. Endocrine and cutaneous immune-related adverse events (irAEs) are among the most frequent irAEs (14-30% and 30-40%, respectively) in patients treated with immune checkpoint inhibitors. What does this study add? Acquired generalized lipodystrophy can occur during anti-PD1 therapy and is associated with severe metabolic complications. With the increase in anti-PD1 prescription in several cancer types, clinicians must be aware of the whole range of irAEs that may occur.

Accuracy of computed tomographic colonography in a nationwide multicentre trial, and its relation to radiologist expertise.

OBJECTIVE: Reports on the accuracy of computed tomographic colonography (CTC) mainly involve series from expert institutions. The aims of this study were to assess CTC accuracy in a nationwide population and to relate it to radiologist performance in their initial training. DESIGN: Nationwide multicentre trial. SETTING: Twenty-eight radiologists, working in 26 mostly academic clinical units, were involved in the study after having attended a formal specialised 2-day training session on CTC. They worked through a training set of 52 cases with automatic feedback after an attempt at each case. PATIENTS: The study enrolled 845 patients with average and high risk of colorectal cancer, 737 of whom had both complete CTC and videocolonoscopy data, which constituted the dataset. INTERVENTIONS: Patients underwent same-day CTC followed by videocolonoscopy with segmental unblinding of CTC results. MAIN OUTCOME MEASURES: Sensitivity, specificity and positive and negative predictive values for detection of polyps ≥ 6 mm in per-patient and per-lesion analyses of CTC without computer-aided detection. RESULTS: Sensitivity, specificity and positive and negative predictive values for patients with polyps ≥ 6 mm were 69% (95% CI 61% to 77%), 91% (95% CI 89% to 94%), 67% (95% CI 59% to 74%) and 92% (95% CI 90% to 94%), respectively. Univariate analysis showed that the detection rate for polyps ≥ 6 mm was linked to neither radiologist case volume nor number of polyps, but was related to sensitivity achieved in the training set. Pooled sensitivity was 72% (95% CI 63% to 80%) versus 51% (95% CI 40% to 60%) for radiologists achieving above and below median sensitivity in the training set (61%), respectively. Multivariate analysis showed that sensitivity for polyps ≥ 6 mm in the training set was the only remaining significant predictive factor for subsequent performance. CONCLUSIONS: Radiologist sensitivity CTC for detection of polyps ≥ 6 mm in training was the sole independent predictor for subsequent sensitivity in detection of such polyps.

[Diffusion-weighted MR imaging of the breast]. / Diffusion en IRM mammaire.

Diffusion-weighted imaging is helpful to further characterize lesions that remain indeterminate after morphological and dynamic MR evaluation. Suspicious lesions are hyperintense on diffusion-weighted images with corresponding low ADC values, indicating restricted diffusion and hypercellularity. Benign lesions and tumors responding to treatment usually have no diffusion restriction. ADC maps are useful for T2W hyperintense lesions that could mask the presence of restricted diffusion. Image fusion is sometimes needed to accurately localize enhancing lesions on ADC maps. For indeterminate lesions, a hypocellular appearance suggests a lower ACR category whereas the presence of restricted diffusion suggests a higher category.

[Pneumatosis cystoides intestinalis complicating paraneoplastic dermatomyositis]. / Pneumatose kystique intestinale compliquant une dermatomyosite paranéoplasique.

BACKGROUND: Pneumatosis cystoides intestinalis (PCI) is a rare condition characterized by the presence of gas-filled cysts within the wall of the digestive tract. Classically, it occurs in lung or colon diseases but rarely in patients with collagen disorders. We report a new case of PCI occurring during the course of paraneoplastic dermatomyositis. PATIENTS AND METHODS: A 53-year-old woman was diagnosed with dermatomyositis two years ago. Relapse of dermatomyositis preceded the discovery of metastases for which chemotherapy was initiated with 5-fluorouracil and vinorelbine. Three months later, she was admitted to our department for abdominal pains. On physical examination, the abdomen was distended with normal peristalsis. There was no evidence in favour of active dermatomyositis. Abdominal computed tomography scan showed gas collection in the mesentery, revealing the PCI. There was also pneumoperitoneum. The patient slowly improved with symptomatic treatment. DISCUSSION: PCI is uncommon in systemic diseases and extremely rare in dermatomyositis. The pathogenesis and aetiology of PCI are unknown in most cases. In collagen diseases, several hypotheses have been suggested: digestive hypokinesia, corticosteroid-induced ulceration and intestinal vasculitis. In our patient, two factors contributed to PCI: corticosteroid administration and a chemotherapeutic agent (vinorelbine), resulting in severe constipation. Diagnosis of PCI is based on abdominal computed tomography. Pneumoperitonitis is frequent. Although rare, the diagnosis of PCI must be evoked in collagen disorder patients presenting nonspecific abdominal symptoms.

[Diagnosis of a malignant lymph node]. / Le diagnostic d'un ganglion tumoral.

There are several imaging techniques, each with advantages and limitations. Standard or computed radiography is always useful. CT diagnosis of an enlarged lymph node is easy but it is very difficult to conclude about its reactive or metastatic nature: subtle signs can help. MRI has similar pitfalls but sometimes it may be possible to identify fibrotic scarred nodes. US with Doppler can evaluate the abnormal angioarchitecture of a metastatic lymph node. Sentinel lymph nodes are easily identified by nuclear medicine. CT-PET provides morphologic and metabolic information which increases the diagnostic accuracy. Imaging work-up strategies for selected malignancies are discussed.

Cerebral tuberculosis in patients with the acquired immunodeficiency syndrome (AIDS). Report of 6 cases and review.

Cerebral tuberculosis (TB) was diagnosed in 6 (4%) of 156 HIV-infected patients with TB seen at our institution over 6 years. We describe here the clinical and radiologic features of these cases and of 15 others reported in the literature. Of the 21 patients, 59% were intravenous drug users. Presenting symptoms were fever (76%), confusion (52%), seizures (38%), and headache (38%). Fourteen patients (66%) had previous or active extracerebral TB at presentation. Cranial CT scan showed ring-(62%) or nodular-(24%) enhancing lesions or mixed forms (14%). Among the 12 patients who underwent a brain biopsy, bacteriologic evidence of TB was found in 9. Four patients (19%) died during hospitalization. Among the 17 others who received antituberculous therapy, only 1 developed neurologic sequelae. Five patients also received steroid therapy to control cerebral edema or paradoxical growth of the cerebral mass lesions. TB should be considered as a cause of cerebral mass lesions in HIV-infected patients, especially if tuberculous infection is suspected at other sites.

Pulmonary Mycobacterium avium complex disease without dissemination in HIV-infected patients.

Pulmonary disease due to Mycobacterium avium complex (MAC) without evidence of dissemination is uncommon in HIV-infected patients. Five cases were observed over a 2-year period. All patients had AIDS and the median CD4 cell count at the time of presentation was 90 x 10(6)/L. Radiographic patterns included unilobar alveolar infiltrates or diffuse alveolar densities. All patients had a favorable clinical response to antimycobacterial chemotherapy with a median follow-up period of 10 months. MAC should be considered in HIV-infected patients with positive respiratory samples for acid-fast bacilli and pulmonary infiltrates. Patients with such findings in whom presumptive therapy for tuberculosis has failed should receive broad-spectrum antimycobacterial chemotherapy until final identification is available.

Factor analysis of medical image sequences in MR of head and neck tumors.

PURPOSE: To evaluate factor analysis of medical image sequences (FAMIS), a means whereby physiologic contrast enhancement kinetics, called factors, and their spatial distribution, termed factor images, are estimated after acquisition of dynamic MR images. The method is intended to recognize and characterize the different tissue kinetics automatically. METHODS: This method was evaluated in a series of 22 patients with head and neck tumors. Eleven patients presented with a previously untreated lesion. Six were examined for tumor recurrence, previously treated by multiple therapies. Five patients had preoperative chemotherapy and underwent MR before and after chemotherapy. In all cases, MR images were correlated with surgical and pathologic data. MR examinations were performed on a 1.5-T unit with static sequences and dynamic sequences acquired after bolus injection of gadolinium and processed by FAMIS. RESULTS: FAMIS was able to identify three factors representing contrast-enhancement kinetics and their associated factor images. The neoplastic component was associated with the earlier factor image, F1. Fibrosis and chemotherapy and/or radiation-induced changes were associated with the two later factors, F2 and F3. The limits of this method were highly vascularized tissues whose earlier factor was similar to that of neoplastic tissues (mucosae and salivary glands), patient motion, responsible for artifacts in FAMIS, and lesions of less than 5 mm. CONCLUSION: FAMIS of dynamic MR studies was useful for differentiating neoplastic tissue from tissue having undergone changes by chemotherapy and/or radiotherapy, but it did not improve the ability of MR to characterize neoplastic tissues in previously untreated patients.

Cervicomediastinal magnetic resonance imaging in persistent or recurrent papillary thyroid carcinoma: clinical use and limits.

Cervicomediastinal magnetic resonance imaging (MRI) was evaluated in 13 consecutive persistent or recurrent papillary thyroid carcinoma (PTC) patients, previously treated by total thyroidectomy and radioiodine ablation. All had elevated thyroglobulin (Tg) levels and were therefore submitted to a new therapeutic radioiodine dose followed by a posttherapeutic whole-body scan (131I-WBS) and subsequent MRI. Patients with known distant metastases were excluded from the study. Group 1 included 7 patients with a negative 131I-WBS, whereas cervical and/or mediastinal 131I-uptake was evidenced in the other 6 patients (group 2). MRI was thus compared to 131I-WBS, and additionally in 8 reoperated cases, to histology. MRI was positive in 11 of 13 (85%) patients, corresponding to 23 of 55 (41.8%) histologically confirmed sites. In group 1, MRI was positive in 5 of 7 patients, with a sensitivity of 47% (15/32 histologically positive sites), allowing appropriate indication of surgery: 4 neck surgery, and 1 mediastinal dissection because of too distant lymph node foci. In group 2, MRI always showed more localization than 131I-WBS; histology was obtained in 3. Because all the foci located in the mediastinal area (0.8 to 1.8 cm) were histologically confirmed (7/7 sites), MRI avoided underestimation of surgery in the 8 reoperated patients. However, additional images were also observed corresponding to a normal thymus, a small neuroma or inflammatory lymph nodes, but pretracheal and very small nodes (less than 0.5 cm) were missed. In conclusion, although less specific than radioiodine scintigraphy, MRI can detect local persistent or recurrent PTC, and seems particularly effective for evaluation of mediastinal involvement.

Computed radiography.

In several medical centers computed radiography has almost completely replaced the use of conventional screen-film systems for general radiography. The aim of this paper is to explain the basic principles of the four most frequently numerical detectors used in the world, with emphasis on the phosphor plates, which are the most frequently used both in hospitals and by practitioners. The other two systems are based on a receptor with selenium. The fourth uses charged coupled device (CCD) detectors. The most important principles of digital processing are then described with concentration on unsharp mask filtering. In the future computed radiography will replace standard radiology and will create a system in medicine using the power of computers to archive--with more efficiency and less space--patient medical data. The transmission of data to workstations and the processing of this data is the topic of a new field in medicine.

Chest high resolution CT in adults with primary humoral immunodeficiency.

The purpose of this study was to assess the findings on chest high resolution computed tomography (HRCT) in patients with primary humoral immunodeficiency. HRCT was prospectively and consecutively performed in 19 patients with primary humoral immunodeficiency, aged 15-64 years (mean 36), and in 15 healthy subjects. HRCT results were correlated with clinical and biological data. Bronchial lesions were observed in 11 patients (58%), consisting either of bronchial wall thickening in eight or bronchiectasis in eight; both were present in five patients. Lobar and/or segmental collapses were found in seven patients (37%), scars in eight patients (42%), interstitial lesions in six patients (32%), and lobular air-trapping in two patients (11%). Parenchymal collapses were correlated with the annual frequency of infections (p = 0.03) and with the IgA level (p = 0.01). Scars were correlated with the annual frequency of infections (p = 0.04). No correlation was found between bronchial wall thickening or bronchiectasis and the data analysed. In conclusion, HRCT is a useful method to demonstrate lung disease in primary humoral immunodeficiencies, with special emphasis on bronchial changes and interstitial lesions.

Magnetic resonance imaging in patients with penile carcinoma.

The aim of the study was to determine the role of pre-operative magnetic resonance imaging (MRI), with and without contrast enhancement, in patients with penile carcinoma. Nine patients with a penile cancer were studied. The staging of the tumours was performed by clinical examination, MRI and surgery, according to the TNM classification. Six patients had primary tumours, of clinical stage T1 (n = 1) and T2 (n = 5). Three other patients had been previously treated and presented with a local recurrence of clinical stage T2. Surface-coil MRI was performed at 0.5 T with T1 weighted sequences before and after gadolinium-DOTA, and T2 weighted sequences. MRI results were compared with the clinical and surgical findings. T1 weighted sequences did not clearly demonstrate the margins of the tumours. T2 weighted sequences were the more useful in five patients, whereas contrast enhanced T1 weighted sequences allowed better delineation of the lesions in only three patients. Therefore, an imaging protocol should include spin echo T2 weighted sequences. Clinical examination correctly staged six of nine tumours; MRI, seven of nine tumours and the combination of both examinations, eight of nine tumours. MRI provided good evaluation of tumoral invasion into the penile shaft.

[Hereditary multiple exostoses after 40 years of development: a case report]. / Maladie des exostoses multiples après 40 ans d'évolution: à propos d'un cas.

INTRODUCTION: Hereditary multiple exostoses is an autosomal dominant skeletal disorder with genetic heterogeneity and an estimated prevalence of 1/50,000 in western countries. Malignant degeneration is a rare (about 2%) but classical complication in patients with hereditary multiple exostoses. At least 3 loci identified as EXT 1, EXT 2 and EXT 3 are involved in this skeletal disease. EXEGESIS: The case of a 45-year old man is described with 15 years follow-up after resection of a well-differentiated chondrosarcoma (grade I), which arose from a right posterior pelvic exostosis. The observed radiological lesions remained relatively stable until now. The genetic mutation which is responsible for the disease was determined at the locus EXT 1. CONCLUSION: The present case report illustrates the natural history of hereditary multiple exostoses, especially since the patient underwent a malignant degeneration which could be resected without recurrence. The results of the genetic analysis contributed to the understanding of the pathophysiology of the disease.

[Techniques to improve the accuracy of CT-guided abdominal biopsy]. / Techniques permettant d'améliorer la rentabilité des ponctions abdominales sous scanner.

STUDY AIM: The aim of this paper is to present an overview of the various technical progresses made in the field of CT-guided abdominal biopsies. Recent improvements allowed to markedly increase the efficiency of biopsies and to decrease the number of complications. The main innovations concern the guidance technique itself with the availability of ultra-fast CT systems, the development of automated biopsy systems, which allow to improve the size and quality of tissue samples and numerous technical tricks, allowing an easier access to target lesions, either in patient positioning or in displacement of anatomical structures. A better management of tissue samples favored by a close collaboration with pathologists is also mandatory. The last section of the paper is an overview of the rare complications of CT-guided biopsies.

[Fatty replacement of the pancreas in a patient with asymptomatic pulmonary cystic fibrosis]. / Infiltration graisseuse du pancréas dans le cadre d'une mucoviscidose asymptomatique sur le plan pulmonaire.

The authors report the case of a 26-year-old woman with hepatomegaly, who had recurrent and progressive nausea and abdominal pain. Computed tomography and magnetic resonance imaging demonstrated fatty replacement of the entire pancreas resulting from cystic fibrosis. The pulmonary disease was totally asymptomatic. Fatty replacement of the pancreas is the most frequent pattern in older patients with cystic fibrosis. This pattern correlates with pancreatic exocrine dysfunction.

[Digital thoracic radiology: devices, image processing, limits]. / Radiographie thoracique numérisée: appareillages, traitements d'images, limites.

In a first part, the different techniques of digital thoracic radiography are described. Since computed radiography with phosphore plates are the most commercialized it is more emphasized. But the other detectors are also described, as the drum coated with selenium and the direct digital radiography with selenium detectors. The other detectors are also studied in particular indirect flat panels detectors and the system with four high resolution CCD cameras. In a second step the most important image processing are discussed: the gradation curves, the unsharp mask processing, the system MUSICA, the dynamic range compression or reduction, the soustraction with dual energy. In the last part the advantages and the drawbacks of computed thoracic radiography are emphasized. The most important are the almost constant good quality of the pictures and the possibilities of image processing.

[Digital radiography of the thorax]. / Radiologie numérique du thorax.

Digital radiography of the thorax can, now be substituted to conventional chest radiography. Computed radiography with phosphor plates and the new selenium detector are emphasized. The major image processing are explained. Successively the main other methods of digital radiography are described: scanning equalization radiography, laser-digitized radiography and multiwire proportional chambers. Then the advantages and the drawbacks of chest computed radiography are extensively reviewed.

[Scanner-guided biopsy technic with abdominal compression]. / Technique de la biopsie abdominale sous scanner avec compression.

The aim of this study was to present a CT-guided biopsy technique using an abdominal compression device. With this system, the digestive structures (mainly the colon and the small bowel) can be displaced away from the needle track and the distance between the skin and the target lesion can be reduced by approximately one-third. The technique has been used in 29 patients and was successful in 28, allowing node biopsies in the mesenteric, retroperitoneal or pelvic areas. The compression system is easily mounted and used standard sterilizable material. The procedure is well tolerated by patients and complication rate is not raised compared with conventional biopsy techniques.

[Cervico-mediastinal recurrences of differentiated thyroid cancers: value of MRI]. / Récidives cervico-médiastinales des cancers thyroïdiens différenciés: valeur de l'irm.

AIM: The aim of this study was to evaluate the ability of MRI to detect recurrent differentiated thyroid carcinomas developed in the neck or the upper mediastinum. RESULTS: MRI was performed in 25 patients, and was compared in 5 cases with surgery. In 20 cases it was compared with I-131 scintigraphy (100 mCi in 14 cases and 5 mCi in 6 cases). The sensibility, specificity and overall accuracy of MRI was respectively: 100%, 66.6%, 82.6%. COMMENTARY: MRI is a good technique to detect recurrent thyroid carcinomas. It is specially interesting to investigate patients with a biological suspicion of recurrence and a negative scintigraphy. Mediastinal localisations that cannot be detected by US can be detected by MRI.