[Febrile cellulitis surrounding a scar revealing a large immunoblastic B-cell lymphoma]. / Dermohypodermite fébrile péricicatricielle révélatrice d'un lymphome B immunoblastique à grandes cellules.

BACKGROUND: Secondary skin sites of lymphoma appear in the advanced stages of the disease. We report the first case of a pericicatricial skin infiltration, mimicking febrile dermohypodermitis, revealing diffuse immunoblastic large B-cell non-Hodgkin's lymphoma. PATIENTS AND METHODS: Four months after decompressive cervical laminectomy, a 56-year-old man presented an inflammatory pericicatricial patch evoking cellulitis in a setting of hyperthermia and lymphadenopathy. Blood cultures and bacteriological analysis of skin biopsy samples were negative. The images showed infiltration of the soft subcutaneous areas and polyadenopathy. Two weeks later, several subcutaneous nodules appeared on the trunk. Histological analysis and immunolabelling pointed to immunoblastic large B-cell non-Hodgkin's lymphoma. A clone of B lymphocytes CD45+, CD20+, CD79a+, Bcl2+, CD5+, MUM1+, CD3-, CD10-, CD23- and Bcl6- was seen. The remainder of the extension examination was negative. CHOP-rituximab polychemotherapy resulted in complete regression of all lesions, notably the inflammatory cervical plaque. DISCUSSION: Secondary skin manifestations of lymphoma are generally non-specific (pruritus, ichthyosis, purpura, etc.) rather than specific in terms of lymphoid infiltration. As in our patient, certain cutaneous sites of lymphoma may have a misleading clinical presentation, histological analysis alone was able to provide a conclusive diagnosis. In our patient, the highly specific infiltration seen around the entire scar could either suggest a Koebner phenomenon or point to a role of the cutaneous aggression within the development of an inflammatory process contributing to pericicatricial infiltration by lymphoid cells. Locoregional invasion from the osseous part of the cervical spine and not macroscopically diagnosed during neurosurgery could also be responsible.

[Syringotropic and pilotropic cutaneous T-cell lymphoma without follicular mucinosis]. / Mycosis fongoïde syringotrope et pilotrope sans mucinose folliculaire.

BACKGROUND: Mycosis fongoides rarely exhibits predilection for infiltration of hair follicles and eccrine glands. We report the case of a patient with cutaneous T-cell lymphoma with syringotropism and pilotropism without follicular mucinosis. CASE REPORT: A 51-year-old man presented with erythematous infiltrated patches with alopecia and anhydrosis, cystic lesions, comedon-like lesions, follicular keratosis and an ulcer over the lower left leg. Clinical examination revealed no palpable adenopathy or hepatosplenomegaly. The patient complained about hypohydrosis. Histological examination of skin biopsies evidenced pilotropic cutaneous T-cell lymphoma without follicular mucinosis. Immunohistological examination and T-cell receptor B-chain gene rearrangement analysis showed a clonal population of T-cells. Moreover sweat glands and sweat ducts were infiltrated by atypical lymphocytes with syringolymphoid hyperplasia. DISCUSSION: Syringolymphoid hyperplasia and folliculotropism without follicular mucinosis are rarely seen in mycosis fongoides. Deep biopsies of adnexal structures are required for this critical diagnosis and clonal rearrangement of TCR genes is a reliable means of assessing clonality. Syringolymphoid hyperplasia and pilotropism without mucinosis are variants of cutaneous T-cell lymphomas.

[A persistent ulceration after a fortuitous BCG revaccination]. / BCGite après une revaccination accidentelle par le BCG.

INTRODUCTION: We report a cutaneous ulceration which occurred following a BCG revaccination. OBSERVATION: A 17 year old man, without previous history, presented a large and slow progressive ulceration of the left deltoid area following a fortuitous BCG revaccination. He did not complain of any other symptom. The swab culture from the exudate isolated Mycobacterium bovis whereas the direct analysis by Ziehl staining was negative. The ulceration healed in four months with local and systemic treatment with isoniazid. DISCUSSION: BCG vaccination side effects are largely described and can be either nonspecific, like with all vaccinations, or specific and due to the infection with Mycobacterium bovis. It can behave like an infectious agent or an immunogenic agent. The BCG revaccination complications are much less known because there are only few publications in the literature. In our case, the mechanism may have been infectious or imply immune reaction with Arthus'type-phenomenon and/or a type IV hypersensitivity. CONCLUSION: Adverse reactions due to revaccination are rarely described should became less frequent when the BCG revaccination is abandoned following the decision of French regulatory authorities. Nevertheless, such complications can occur by accident, as the case in our patient.

Chronic thalamic stimulation with three-dimensional MR stereotactic guidance.

PURPOSE: To report a method of electrode implantation in the ventralis intermedius nucleus of the thalamus for the treatment of tremor using a 3-D stereotactic MR imaging technique. METHODS: Five patients (three men and two women; mean age, 59 years) with medically refractory tremor had intrathalamic implantation of a stimulating electrode. Stereotactic MR imaging was performed on a 1.5-T unit equipped with an MR-compatible Leksell G stereotactic frame fixed to the patient's head. Calculation of the coordinates of the theoretical target was based on the coordinates of the anterior commissure, the posterior commissure, and the midline sagittal plane as determined via stereotactic MR imaging. During the surgical procedure, the best position for the stimulating electrode was determined by electrophysiological and clinical studies. Postoperative MR control studies were done in all cases to verify the position of the electrode. RESULTS: Stereotactic MR imaging allowed precise implantation of the stimulating electrode in all patients. Electrode stimulation produced a 90% reduction of the tremor in two patients, an 80% and 70% reduction in one patient each, and a persistent microthalamotomy-like effect in the fifth patient. Examination of the MR control studies showed that mean error in the positioning of the electrodes was 0.77 +/- 0.6 mm (mean +/- SD) in the x direction and 0.80 +/- 1.02 mm in the y direction. CONCLUSION: Although our series is relatively small, the precision achieved with stereotactic MR imaging proves that it can be used with confidence for precise functional neurosurgical procedures.

Registration in neurosurgery and neuroradiotherapy applications.

Because of the high level of accuracy needed in neurosurgery, many computer-assisted surgery (CAS) and augmented reality techniques have been developed in this field. A common issue with all of these techniques is registration between preoperative three-dimensional images (computed tomography and magnetic resonance imaging) and the patient in the operating room. We present, in the first part of this paper, a survey of the latest CAS technologies, using fully automatic registration without fiducial landmarks. All of the registration algorithms described are based on minimization of a cost function. We then describe our approach. Our cost function is simply the mean square error (MSE), minimized by the iterative closest point algorithm (ICP). Because the weak point of the ICP algorithm is the closest point computational cost, we precalculate it by a "closest point map," inspired from classical distance map. We finally perturb the found solution to eliminate local minima close to the global minimum. This paper summarizes the various methods presented. We study the shape of the different cost functions and show that there is no need for a complex cost function. MSE has sufficiently good convergence properties to reach a position very close to the global minimum. We also demonstrate the influence of a final perturbation of the found solution to improve registration. Finally, we test the registration on different regions of the patient's head.

[Reformatting 3-dimensional medical images. Application to MRI and scanners]. / Recalage d'images médicales tridimensionnelles. Application à l'IRM et au scanner.

Several kinds of images, each giving a different information, are now available to radiologists. The MRI images have excellent contrast resolution and enable soft tissues to be differentiated, but they do not distinguish structures with low water content, notably air and bone, whereas these are easily recognized by CT. The aim of this study is to present a simple, entirely radiologist-supervised method to examine the radiological data of any patient, obtained from several kinds of images. MRI is performed using a GEMS Signa, 1.5 Tesla, 4.9 version magnet. Acquisitions are T1- or T2-weighted spin-echo or gradient sequences, with a 256 or 512 matrix, on axial sections, with of without contrast injection. CT is performed using a GEMS Hi Speed scanner. Acquisitions are obtained on a 512 matrix and with a "Soft" or "Bone" filter, without contrast injection. The two series of sections are transmitted, through an Etherne network, to a Sun console where the two corresponding volumes are reconstructed on a GEMS Voxtol by means of a 3-dimensional soft ware for image treatment. At least 3 couples define the rotation and translation required for one of the two volumes to reset it in the guide mark of the other. The soft ware then looks for the best transformation, in terms of least square, between the two 3-dimensional volumes. The calculation demands only a few seconds. One of the two objects is then recalculated in the guide mark of the other. The cursor positioned by the user on any point of the object is linked to a second cursor which will automatically position itself on the corresponding point of the other object. The accuracy obtained (about one millimeter) is specified by the soft ware which indicates how to improve resetting. In addition to its teaching value, this superimposition image can help in the diagnosis and can be used for surgical stimulation because it is possible to mix the images. This mixing gives access to a new type of imaging, since the images spared can be reconstructed in volume, and treated in all planes, as a CT or MRI examination. The term "Anatomical Reconstruction Images" may be suggested for this new type of examination. Beside intermodal comparison, one may also imagine that the soft ware can be used to follow up the patient over time (repeat MRI) or to make comparisons between several objects, although the elastic resetting method is more often appropriate in the second case.