R-CHOP appears to be the best first-line treatment for second primary diffuse large B cell lymphoma: a cancer registry study.

Second primary diffuse large B cell lymphoma (spDLBCL) is defined as a metachronous tumor occurring after a first primary cancer. To date, while R-CHOP is the standard first-line treatment for de novo DLBCL, no available data show that R-CHOP is the optimal treatment for spDLBCL. This exploratory study aimed to investigate treatment of spDLBCL. From 2008 to 2015, the Poitou-Charentes general cancer registry recorded 68 cases of spDLBCL ≤ 80 years old, having received a first-line treatment with either R-CHOP (78%) or other regimens (22%). Patients without R-CHOP have worse overall survival in univariate (HR 2.89 [1.33-6.24], P = 0.007) and multivariate (HR 2.98 [1.34-6.67], P = 0.008) analyses. Patients without R-CHOP more frequently had PS > 1 (67% vs. 28%, P = 0.007) and prior chemotherapy (60% vs. 26%, P = 0.02), which suggests that both of these factors influence a clinician's decision to not use R-CHOP. Prior chemotherapy had no prognostic impact in univariate and multivariate analyses; this result could call into question the risk-benefit balance of not using R-CHOP to prevent toxicity. In our study, one DLBCL out of ten occurred after a first primary cancer, and as regards de novo DLBCL, R-CHOP appeared to be the best first-line treatment. Larger series are needed to confirm these results.

Non-invasive diagnosis of intracranial aneurysms.

Patients need to be examined for intracranial aneurysms if they have had a subarachnoid hemorrhage. The preferred technique in this situation is CT angiography. Screening can be done for familial forms or for elastic tissue disorders, for which the first line investigation is magnetic resonance angiography. These non-invasive methods have now taken over from conventional angiography that was reserved for the pretreatment phase. A good technical knowledge of these imaging methods, their artifacts and misleading images enables reliable detection of intracranial aneurysms and for an accurate report to be returned to clinicians.

Imaging of cervical artery dissection.

Cervical artery dissection (CAD) may affect the internal carotid and/or the vertebral arteries. CAD is the leading cause of ischemic stroke in patients younger than 45 years. Specific treatment (aspirin or anticoagulants) can be implemented once the diagnosis of CAD has been confirmed. This diagnosis is based on detection of a mural haematoma on ultrasound or on MRI. The diagnosis can be suspected on contrast-enhanced MRA (magnetic resonance angiography) or CT angiography, in case of long stenosis, sparing the internal carotid bulb, or suspended, at the junction of V2 and V3 segments of the vertebral artery, in patients with no signs of atheroma of the cervical arteries. MRI is recommended as the first line imaging screening tool, including a fat suppressed T1 weighted sequence, acquired in the axial or oblique plane at 1.5T, or 3D at 3T. Complete resolution of the lumen abnormality occurred in 80% of cases, and CAD recurrence is rare, encountered in less than 5% of cases. Interventional neuroradiology (angioplasty and/or stenting of the dissected vessel) may be envisaged in rare cases of haemodynamic effects with recurring clinical infarctions in the short-term.

Does anticoagulation promote mural hematoma growth or delayed occlusion in spontaneous cervical artery dissections?.

BACKGROUND: In case of spontaneous cervical artery dissection (CAD), a medical treatment with anticoagulant or antiplatelet (AP) drugs would avoid the occurrence of an ischemic stroke. Although immediate anticoagulation (AC) is advocated, evidence from randomized trials is lacking. Since CAD is characterized by a mural accumulation of blood, the dissecting hematoma may enlarge under AC, with subsequent lumen narrowing. Although direct evidence of mural hematoma enlargement is lacking in the literature, such a complication may not only be theoretical. Magnetic resonance imaging (MRI) of the mural hematoma on transverse sections through the neck is the current diagnostic gold standard. Our aim was to compare the evolution of the mural hematoma in CAD during the first week after treatment initiation (AP agent: groupAP, AC: groupAC), using dedicated cervical MRI of the arterial wall. METHODS: The study was -approved by the Ethics Committee of Ile de France III. Informed consent was waived. The manuscript was prepared in accordance with the STROBE statement. Fast spin-echo T1-weighted fat-suppressed axial sequences were performed at admission (MRI1) and during the first week after initiation of the treatment (MRI2). Two readers measured volumes, craniocaudal length of the mural hematoma and lumen patency, and searched for early recurrent CAD. They also searched for extension or recurrence of ischemic brain lesions and for hemorrhagic transformation on diffusion-weighted imaging (DWI) and gradient echo T2 (T2*) sequences, respectively. RESULTS: The population included 44 patients (31 in groupAC, 13 in groupAP) with 49 CAD (35 carotid, 14 vertebral). Recurrent CAD and reduction of the lumen did not occur in either group. We did not observe recurrent DWI lesions or occurrence of hemorrhagic transformation. Interobserver agreement [intraclass correlation coefficient (95% CI)] was excellent for volume measurement [0.98 (0.97-0.99) and 0.99 (0.98-1.0) for volume1 and volume2, respectively]. While mean volumes and length of the mural hematoma decreased after treatment in both groups (volume: groupAC -13 ± 22%, groupAP -12 ± 24%, p = 0.33; length: groupAC -10 ± 27%, groupAP -10 ± 20%, p = 0.18), approximately one third of patients in each group had some growth of the mural hematoma as well as an increase in length. CONCLUSION: Limited growth of the mural hematoma was seen with both treatments in approximately one third of patients during the first week after treatment initiation. However, neither AC nor AP agents promote reduction of the lumen or recurrent dissection.

Brain arteriovenous malformation diagnosis: value of time-resolved contrast-enhanced MR angiography at 3.0T compared to DSA.

INTRODUCTION: This study was conducted in order to evaluate the value of time-resolved contrast-enhanced magnetic resonance angiography (TR-CE-MRA) with a 3.0-T magnetic field compared to digital subtraction angiography (DSA) as the reference standard for the diagnosis of brain arteriovenous malformation (bAVM). METHODS: Nineteen patients with 19 angiographically confirmed untreated bAVM were investigated with both DSA and TR-CE-MRA for the initial diagnosis. Examinations were compared by two independent readers. Interobserver agreement and intermodality agreement with respect to nidus size, arterial feeders, and venous drainage were determined using the K statistic test. Also, the quality of the TR-CE-MRA images was evaluated. RESULTS: Seventeen of the 19 bAVM (89.5%) detected with DSA were diagnosed with TR-CE-MRA. Interobserver agreement for TR-CE-MRA was good for nidus size, venous drainage, and arterial feeders (K = 0.75, 95% CI 0.50-1.00; K = 0.77, 95% CI 0.54-1.00; and K = 0.80, 95% CI 0.59-1.00 respectively). Intermodality agreement was good for nidus size and venous drainage (K = 0.75, 95% CI 0.49-1.00 and K = 0.77, 95% CI 0.54-1.00, respectively) and moderate for arterial feeders (K = 0.44, 95% CI 0.17-0.70). CONCLUSION: TR-CE-MRA at 3.0 T has a good sensitivity for bAVM detection and good agreement with DSA for determining nidus size and the type of venous drainage, suggesting that TR-CE-MRA is potentially a reliable tool for the diagnosis and assessment of bAVMs. However, it still suffers from low spatial resolution and vessel superposition, making differentiation of the arterial feeders of the nidus difficult at times.

Trigeminal neuralgia related to arteriovenous malformation of the posterior fossa: three case reports and a review of the literature.

OBJECTIVE: To describe the rare association of trigeminal neuralgia (TGN) with a brain arteriovenous malformation (bAVM) of the posterior fossa. PATIENTS AND METHODS: This is a report of three patients presenting with TGN due to vascular compression by a bAVM of the posterior fossa, with emphasis on clinical presentation, diagnostic imaging, management and follow-up. Magnetic resonance imaging (MRI) was performed with sequences in thin slices in the same section plane using a 3D time of flight (TOF) and axial T2-weighted driven equilibrium (DRIVE) of the posterior fossa. RESULTS: No bleeding episodes were documented in the three patients. MRI and digital subtraction angiography (DSA) showed a posterior fossa bAVM with a nidus surrounding the trigeminal nerve, fed by arteries from the carotid and vertebrobasilar systems. Within a few days, medical treatment effectively alleviated the symptoms, with no more pain during follow-ups at 6, 10 and 18months. No invasive treatment was performed because the bAVMs were considered to have a low risk of bleeding. CONCLUSION: TGN related to a bAVM can mimic classical TGN. MRI and DSA are the imaging methods of choice. Medical treatment remains the first line of therapy, but if that fails, multimodal invasive treatment may be an alternative for pain relief.