Implantation of fiducial markers in the liver for stereotactic body radiation therapy: Feasibility and results.

PURPOSE: Robotic stereotactic body radiation therapy (SBRT) for the treatment of hepatocellular carcinoma requires the perilesional implant of gold fiducial markers for detection by scopy. The purpose of this study is to determine whether the implant of gold fiducial markers is still possible and, if so, with which imaging technique and with what results. MATERIALS AND METHODS: This is a prospective study based on the implant of fiducial markers in the liver in our department for a treatment by SBRT for a hepatocellular carcinoma in 38 patients (49 lesions to treat) over a period of one year. As the first choice, it consisted of sonographic guidance and, if not possible, CT-scan guidance was used. RESULTS: The mean number of fiducial markers implanted per procedure was 2.68(±0.61) with almost exclusive sonographic guidance (36 out of 38 patients or 95% of the patients). The mean distance between the markers and the lesion was 32mm (±11mm) and that between the markers was 17mm (±7mm). CONCLUSION: SBRT is being evaluated for the treatment of liver lesions. The radiologist has an important role to play since the implant of fiducial markers in the liver is indispensable. It is almost always possible with sonographic guidance, including for lesions not accessible to microbiopsies, a treatment by radiofrequency or for lesions poorly individualisable by sonography or CT-scan.

CT assessment of woodworkers' nasal adenocarcinomas confirms the origin in the olfactory cleft.

BACKGROUND AND PURPOSE: Endoscopic endonasal surgery let us observe that woodworkers' nasal adenocarcinomas originate in the olfactory cleft. Our aim was the identification of CT imaging features that corroborate the olfactory cleft as the site of origin for woodworkers' adenocarcinoma. MATERIALS AND METHODS: We designed a retrospective study to compare CT scans of 27 unilateral olfactory cleft adenocarcinomas with 30 cases of nasosinusal polyposis (NSP) and 33 healthy sinus controls. Enlargement of the olfactory cleft, lateralization of the ethmoidal turbinate wall, and contralateral bulging of the nasal septum were measured on coronal scans passing through crista galli and posterior half of both ocular globes. Comparisons have been performed by using analysis of variance and the Bonferroni procedure. RESULTS: The nasal septum was significantly bulging across the midline in adenocarcinoma (4.6 +/- 3 mm; range, -0.1-13.7 mm) compared with NSP (0.7 +/- 1 mm; range, -2.1-2.3 mm) or healthy sinus controls (0.5 +/- 1 mm; range, -1.2-2 mm) (P < .001). The olfactory cleft was significantly wider in adenocarcinoma (15.1 +/- 4.5 mm; range, 8.6-25.7 mm) than in NSP (3.6 +/- 0.4 mm; range, 2.8-4.6 mm) or healthy sinus controls (3.3 +/- 0.7 mm; range, 1.4-4.6 mm). The ethmoidal labyrinth width was significantly smaller on the pathologic side in adenocarcinoma (7.2 +/- 2.7 mm; range, 3.2-14.2 mm) than in the control groups (P < .001). Whereas the angle between the conchal lamina and vertical midline was close to zero degrees in NSP (0.03 +/- 2.25 degrees ; range, -5 degrees -3 degrees ) and healthy sinus controls (0.45 +/- 2.13 degrees , range, -5 degrees -5 degrees ), it reached 39.76 +/- 13.83 degrees (P < .001) in adenocarcinoma. CONCLUSIONS: Radiologists should suspect nasal adenocarcinoma on sinus CT scans showing a unilateral expanding opacity of the olfactory cavity.

[Woodworker's nasal adenocarcinoma revealed by anosmia]. / Anosmie révélatrice d'un adénocarcinome nasal chez les travailleurs du bois.

OBJECTIVES: The aim of this article is to report two cases illustrating the origin of woodworkers' adenocarcinoma in the olfactory cleft and to discuss screening, prevention, and surgical approaches. MATERIAL AND METHOD: Retrospective study of the charts of two cases of adenocarcinoma of the olfactory cleft revealed by a loss of the sense of smell. RESULTS: Of 30 consecutive cases of woodworkers' adenocarcinoma of the olfactory cleft observed during the last 3 years, the two cases revealed by anosmia were diagnosed as small tumors located in one olfactory cleft. CONCLUSION: In light of these two cases, we discuss anosmia in the diagnostic screening of this tumor and its consequences in the olfactory cleft: flexible endoscopic examination of the olfactory cleft seems preferable to rigid endoscope examination of the middle meatus at screening; endoscopic resection of the olfactory cleft seems preferable to resection through external approaches; and nasal lavages seem preferable to the Proetz technique for preventive sinus lavage. The new knowledge on adenocarcinoma of the olfactory cleft should be familiar to occupational health physicians, general practitioners, and otorhinolaryngologists because of its practical consequences for screening, diagnosis, prevention, and surgical treatment.

Lumbar hernia: anatomical basis and clinical aspects.

INTRODUCTION: The purpose of this study was to describe the anatomy of the two orifices of the abdominal posterior wall where lumbar hernias could appear. They may protrude through the superficial lumbar triangle (JL Petit) or the deepest superior orifice (Grynfeltt). METHODS: The exact limits were precised by dissections in cadavers to explain the main differences of these two locations. We report two cases of spontaneous lumbar hernias discovered in outpatient clinic. RESULTS: Clinical diagnosis was difficult and both the patients were sent for lumbar lipoma but a meticulous examination gave us a clue. MRI was useful to confirm the defect in the posterior abdominal wall under the 12th rib. Only one patient was operated by a direct approach with a reinforcement of an unabsorbable mesh. No recurrence appeared during follow-up. CONCLUSION: Thanks to clinical and anatomical knowledge, these rare superior lumbar hernias were diagnosed and a correct surgical treatment permitted a quick recovery.

Internal hernias: anatomical basis and clinical relevance.

The aim of this study was to present and discuss the anatomical basis of internal hernias thanks to our clinical experience of 14 cases. Internal hernias are uncommon cases of acute intestinal obstruction when a viscera protrudes through an intraperitoneal orifice, remaining inside the peritoneal cavity. It excludes iatrogenic post surgical hernias. From an anatomical point of view, three kinds of orifices may be interested. The orifice may be normal: epiploic or omental (Winslow's) foramen, or abnormal through a pathologic transomental hole realizing an internal prolapsus or procidentia, without sac. Or this orifice may be a paranormal peritoneal fossa (para duodenal or retrocaecal) acting as a trap for the bowel: these hernias possess a sac and are considered as true hernias. The clinical diagnosis is always difficult. CT scan can be useful confirming the obstruction and leads to an urgent operation. This retrospective study evaluates diagnosis, management and follow-up according to the type of anatomical orifice and delay of surgery.

[CT diagnosis of acute gastric volvulus]. / Diagnostic tomodensitométrique d'un volvulus gastrique idiopathique aigu.

Acute gastric volvulus is an infrequent entity. Management is surgical. Diagnosis frequently is delayed because of the non-specific nature of presenting symptoms. The authors report a case of acute gastric volvulus diagnosed by computed tomography in a 92 year old woman that was confirmed at surgery. The pathophysiology, classification and different presentations of this entity are briefly reviewed. CT findings suggesting gastric volvulus are reviewed as well.

Surgical anatomy of the turbinal wall of the ethmoidal labyrinth.

The upper part of the lateral nasal wall is formed by a common structure or conchal lamina that is attached all along the junction between the ethmoidal roof and the cribriform plate. From this continuous conchal lamina, the different ethmoidal turbinates take their origin. All these structures form a well defined wall that encloses the ethmoidal cells medially and that deserves the name of "turbinal wall of the ethmoidal labyrinth". The objectives of this paper were: 1) to precisely define the anatomical landmarks of the turbinal wall of the ethmoidal labyrinth, and 2) to study, from an anatomical point of view, the consequences of the surgical resection of the middle turbinate. We performed an anatomic study on 12 frozen human heads, cut in a median-sagittal plane, and then photographed with a millimetre scale in order to perform several measurements. The surface of the turbinal wall of the ethmoidal labyrinth can range from 6.1 to 11.3 cm2. The resection of the middle turbinate preserves approximately half of the turbinal wall, this being around 4.3 cm2 (range 2.6 to 6.3 cm2). The conchal lamina appears as the noble sensorial element of the turbinal wall. It can be described as a continuous bone plate, grossly rectangular in shape, measuring approximately 1 cm in height and 3.5 cm in length that forms the lateral wall of the olfactory groove. The anatomic study shows that its dimensions can vary from simple to double in different individuals. It seems to us that instead of considering the difference of height between the cribriform plate and the ethmoidal roof (Keros classification), we should consider the vertical height of the conchal lamina as a potential risk factor in ethmoidal surgery.

[MR-arthrography: general principles and applications]. / L'arthro-IRM: principes et applications.

The recent approval by the French Ministry of Health of the use of intra-articular Gadolinium could promote the increasing use of MR-arthrography in France. Although useful in specific pathologies, it should not be overly prescribed and should be considered only if it provides a more accurate diagnosis than other less invasive techniques. The technical aspects and medico-legal implications of MR-arthrography as well as its various indications are reviewed in this article. There are three possible techniques: indirect MR-arthrography with IV Gadolinium injection, direct MR-arthrography with intra-articular Gadolinium injection and lastly, direct MR-arthrography with intra-articular injection of iodinated contrast media (or saline solution). Indirect MR-arthrography cannot be recommended because of insufficient contrast enhancement and the absence of joint filling. Conversely, direct MR-arthrography allows joint expansion which smooths out capsule and ligaments, better delineates articular surfaces and yields a homogeneous high intensity signal of the entire joint. Direct MR-arthrography with iodinated contrast media combines standard arthrography with conventional MRI. Direct MR-arthrography with intra-articular injection of dilute Gadolinium is associated with T1WI, usually of higher quality than T2WI, even though the latter remains part of the protocol. Although, the last two techniques yield higher image quality and are often performed for various articular pathologies, they should not be randomly carried out in the evaluation of joint pathology. However, they should be recommended as the first step in the diagnosis of painful shoulders or hips in young adults and athletes.

Validation of diffusion methods for macrolide susceptibility testing of Helicobacter pylori.

Helicobacter pylori resistance to macrolides is increasing, and the need for susceptibility testing has become crucial. The only standardized method is agar dilution, which is not adapted to clinical practice. The present work aimed: (1) to optimize the technical conditions and to assess the reproducibility of the E-test and disk diffusion method for macrolides susceptibility testing of H. pylori, and (2) to assess the performances of these two phenotypic methods in detecting strains harboring a resistance mechanism to macrolides. We used 191 isolates collected in nine centers of France and Belgium. Phenotypic tests were performed on Mueller-Hinton agar supplemented with 10% horse blood, inoculated with a 2-day-old H. pylori suspension (10(8) CFU/ml), and incubated for 72 hr at 37 degrees C under microaerophilic conditions. The reproducibility studied on two randomly selected strains was better for disk diffusion than for the E-test for both clarithromycin and erythromycin. For a subset of 10 strains, the MICs of erythromycin and clarithromycin did not differ from more than one two-fold dilution when determined by E-test or agar dilution method. The breakpoints were for MICs: 1 mg/L for both clarithromycin and erythromycin and for inhibition diameters, 22 mm for clarithromycin and 17 mm for erythromycin. There was a 100% concordance between susceptibility to erythromycin and clarithromycin. However, the susceptible and resistant populations were better separated by testing erythromycin. Of 34 resistant strains, two lacked the A2142G and A2143G point mutations in 23S rRNA by PCR-RFLP. None of 15 tested sensitive strains were positive for one of these two point mutations. For clinical practice, we recommend to assess macrolide susceptibility of H. pylori by using one of these two phenotypic methods under the described technical conditions.

Can the human intervertebral disc be compared to a diarthrodial joint?

The joint between human vertebral bodies is traditionally classified as a symphysis, a major cartilaginous synarthrosis. However, it has been suggested by some authors to compare the intervertebral disc (IVD) to a diarthrodial joint. The bases of this comparison are reviewed and discussed. In his description of 1895, Luschka saw the IVD as a diarthrodial joint containing articular cartilages and synovium in the annulus fibrosus. Subsequently, histologic and ultrastructural investigations into the cells and extracellular matrix of the nucleus pulposus (NP) supported the same hypothesis. More recently, the appearances of the IVD in magnetic resonance imaging (MRI) and discography, as well as clinical considerations were interpreted in the same way to simplify understanding of IVD pathology. However, a number of objections involving general, morphological, embryological, biochemical, histologic, radiological and clinical considerations demonstrate the limitations of this hypothesis. The general structural and mechanical principles of joint classification are mentioned to highlight the basic differences between the IVD and a synovial joint. An overview of the development of these joints, and a review of the literature dealing with ultrastructural aspects of the NP, with histopathological studies of the IVD, and with the normal appearance of the IVD on MRI and its age-related changes has led us to refute the hypothesis of this analogy. The IVD cannot be compared to a synovial joint, explaining why most of its pathologic features are quite different from those of a joint of the appendicular skeleton.

The structure of the cartilaginous end-plates in elder people.

Low back pain is the leading cause of work-related disability. Degeneration of the intervertebral disc (IVD), the boundaries of which with age-related changes remain obscure, is considered to be its most important cause. The cartilaginous end-plate (CEP) is the anatomic boundary of the IVD. Since the latter is avascular in adults, the CEP is supposed to play a key role in the metabolism of the IVD. Consequently, it has been postulated that the decrease in permeability of the CEP is the main cause of degeneration of the disc. However, the permeability depends at least partially on the morphologic state of the CEP. Little is known about the age-related changes of the CEP compared to those of the IVD. The objectives of the study were to examine the CEP at different ages, to classify the age-related changes in both the CEP and IVD, and to compare them. The intervertebral discs of the five levels of ten human lumbar spines were collected from cadavers aged from 47 to 78 years, and studied macroscopically and microscopically. Morphologic features of the CEP (thickness, IVD/CEP length ratio, degree of calcification, marrow contacts, CEP-VB and CEP-IVD separations) were measured. Morphologic grades were assigned for both the CEP and the IVD. No significant differences were found with regard to these features in the different age-groups. On the other hand, no significant correlation was found between the morphologic grade of the CEP and that of the IVD, suggesting that the importance of the CEP in disc degeneration may be debatable.

Correlation between IL-8 induction, cagA status and vacA genotypes in 153 French Helicobacter pylori isolates.

The polymorphism of clinical presentations associated with Helicobacter pylori infection is potentially due to differences in the virulence of individual strains. H. pylori virulence has been associated with the ability to induce secretion of interleukin-8 (IL-8), the vacA genotypes, and the cagA status. The aim of this study was to determine the virulence profiles of 153 French H. pylori isolates on the basis of vacA genotypes, cagA status, and IL-8 induction ability. A total of 153 H. pylori isolates from patients with chronic gastritis (n = 74) or gastro-duodenal ulcers (n = 79) was examined for vacA genotypes and cagA status by polymerase chain reaction (PCR) and dot blot, and for their ability to induce IL-8 secretion by HEp-2 cells. The prevalence of vacA genotypes was: s1/m1 44.3%, s1/m2 24.9%, and s2/m2 23.5%. The cagA gene was present in 64% of the strains. IL-8 secretion was induced by 58.7% of the isolates. The presence of the cagA gene was significantly correlated with the s1/m1 vacA genotype and with the induction of IL-8. Thirty-four strains were atypical (cagA-positive/IL-8 noninducer or cagA-negative/IL-8 inducer). vacA genotypes, cagA status, and IL-8 induction ability are not correlated with the presence or absence of ulcer. The cagA status is not sufficient to predict the proinflammatory ability of H. pylori.

Antibody response of patients with Helicobacter pylori-related gastric adenocarcinoma: significance of anti-cagA antibodies.

The aim of this study was to search for a specific antibody pattern in sera from patients suffering from Helicobacter pylori-related gastric adenocarcinoma (GAC). The serological response of 22 patients suffering from GAC, 31 patients with gastroduodenal ulcer, and 39 asymptomatic subjects was analyzed using immunoblotting performed with three H. pylori strains: strain ATCC 43579; strain B110, isolated from a patient with ulcers; and strain B225, isolated from a patient with GAC. In addition, the latex agglutination test Pyloriset Dry was used to analyze ambiguous sera. H. pylori seropositivity was 75% in the GAC group, 61.3% in the ulcer group, and 56.4% in the asymptomatic group. Anti-CagA antibodies were found more often in the GAC group (48.8%) and in the ulcer group (47.3%) than in the asymptomatic group (21.2%). These percentages depended on the strain used as an antigen: in the GAC group, the anti-CagA frequencies were 93.3, 40, and 13.3% with strains B225, B110, and ATCC 43579, respectively. Thus the presence of anti-CagA antibodies was increased in patients suffering from H. pylori-related GAC, in particular when the CagA antigen was from a GAC strain. These data suggest the existence of a CagA protein specifically expressed by H. pylori strains isolated from GAC patients.

Phenotypic changes of Helicobacter pylori components during an experimental infection in mice.

The bacterial pathogen Helicobacter pylori is highly adapted to the human stomach and the clinical isolates show a high diversity which could be due to adaptative changes of the strains passing from one host to another. In order to study these variations, experimental infection of mice was developed and provided three out of the eleven tested strains able to infect C57BL/6 mice: the Sydney strain which is known to be well adapted to mice and two freshly isolated strains from infected patients. Mice were orally infected with one of these three strains (infecting strains) and were killed 45 days later. H. pylori strains were isolated from the stomachs of mice (emerging strains). The three infecting strains were compared to the three emerging strains for protein and lipopolysaccharide profiles, antigenic profiles revealed by Western blot with monospecific sera and genetic status by testing for the cagA gene and the vacA genotype. During the 45 days of infection, H. pylori underwent phenotypic variations which may be attributed to the adaptation from a human to a mouse environment or from an in vitro to a mouse environment. Those variations consisted of an over-expression at the cell surface of a 180-kDa protein and of a decreased expression of proteins of 260 and 120 kDa. Moreover, antigenic variations were shown for the two freshly isolated strains from human: the CagA and VacA antigens were in the saline extracts of the infecting strains only while the UreA, UreB, HspA and HspB were in the saline extracts of both the infecting and the emerging strains. These variations may contribute to the adaptation of the strains to the mouse environment.

Mutation in the peb1A locus of Campylobacter jejuni reduces interactions with epithelial cells and intestinal colonization of mice.

Campylobacter jejuni is one of the leading causes of bacterial diarrhea throughout the world. We previously found that PEB1 is a homolog of cluster 3 binding proteins of bacterial ABC transporters and that a C. jejuni adhesin, cell-binding factor 1 (CBF1), if not identical to, contains PEB1. A single protein migrating at approximately 27 to 28 kDa was recognized by anti-CBF1 and anti-PEB1. To determine the role that the operon encoding PEB1 plays in C. jejuni adherence, peb1A, the gene encoding PEB1, was disrupted in strain 81-176 by insertion of a kanamycin resistance gene through homologous recombination. Inactivation of this operon completely abolished expression of CBF1, as determined by sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE) and immunoblotting. In comparison to the wild-type strain, the mutant strain showed 50- to 100-fold less adherence to and 15-fold less invasion of epithelial cells in culture. Mouse challenge studies showed that the rate and duration of intestinal colonization by the mutant were significantly lower and shorter than with the wild-type strain. In summary, PEB1 is identical to a previously identified cell-binding factor, CBF1, in C. jejuni, and the peb1A locus plays an important role in epithelial cell interactions and in intestinal colonization in a mouse model.