Neo-adjuvant chemoradiotherapy and multivisceral resection to optimize R0 resection of locally recurrent adherent colon cancer.

BACKGROUND: Neo-adjuvant chemoradiotherapy reduces local recurrence in rectal cancer, but there is a paucity of evidence regarding its role for colon cancer. The aim of this study was to evaluate the feasibility and outcomes of a neo-adjuvant chemoradiotherapy (NCRT) approach for locally recurrent adherent colon cancer (LRACC). METHODS: All patients with non-metastatic LRACC treated with NCRT and multi-visceral resection (MVR) from January 2000 to July 2010 were included. The primary outcome was the rate of R0 resection (negative microscopic margins). Secondary outcomes were toxicities, post-operative morbidity and mortality, local recurrence, overall survival (OS) and disease-free survival (DFS). RESULTS: Fifteen patients were identified. Nine primary cancers were located in the sigmoid and 4 in the left colon. Patients were treated with 45-50 Gy in 25 daily fractions and concurrent 5-FU infusion (225 mg/m(2)/day). En-bloc MVR included between 2 and 5 adjacent organs/structures. All but two resulted in R0 resection. One patient had a complete pathologic response and one had minimal residual tumour cells in the resected specimen. Post-operative major morbidity was 33.3%. No mortality occurred. At a median follow-up of 54 months, there were 2 local, 1 regional, and 2 distant lung recurrences. No grade 3 or 4 acute or late toxicities were observed. 5-year OS and DFS were 90.0% and 63.5% respectively. CONCLUSIONS: NCRT followed by MVR is a feasible option for the treatment of highly selected LRACC to achieve R0 resection, while maintaining acceptable treatment toxicity. Short-term oncological results appear satisfactory, including good local control.

Neoadjuvant chemoradiotherapy and multivisceral resection for primary locally advanced adherent colon cancer: a single institution experience.

BACKGROUND: Although there is an extensive body of literature on the role of neoadjuvant chemoradiotherapy (CRT) in the management of rectal cancer, its role in primary locally advanced adherent colon cancer (LAACC) is unclear. OBJECTIVE: To analyzed the outcomes of neoadjuvant CRT and multivisceral resection in the management of LAACC patietns. METHODS: We retrospectively reviewed our institutional Colorectal Carcinoma Database for 33 patients with potentially resectable, non-metastatic primary LAACC who received neoadjuvant CRT followed by multivisceral resection. CRT consisted of external beam radiation (45-50 Gy in 25 daily fractions) and concurrent 5-FU infusion (225 mg/m(2)/day). RESULTS: There were 21 males and 12 females. Median age was 64 (31-83) and median follow-up was 36 months. All patients had microscopically clear resection margins (R0). Complete pathologic response was documented in 1 patient (3%) and 66% had ypT4b disease. Post-operative complications were observed in 36% of patients with no 30-day mortality. The 3-year overall survival and 3-year disease-free survival were 85.9% and 73.7% respectively. Two patients developed a local recurrence. CONCLUSIONS: Neoadjuvant CRT and en-bloc multivisceral resection may result in high rates of R0 resection and excellent local control with acceptable morbidity and mortality in selected patients with LAACC.

[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.

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.

[Splanchnic vein aneurysms: a report of 13 cases]. / Les anévrismes veineux du réseau splanchnique: à propos de 13 patients.

PURPOSE: Splanchnic vein aneurysms are a rare and poorly known entity. From a review of 13 cases and reports from the literature, we have defined the imaging features and modalities for their diagnosis and management. PATIENTS AND METHODS: Retrospective study of 13 patients (7 females, 6 males, mean age of 53.5 years) who presented between 1993 and 2005 with splanchnic vein aneurysms. All patient charts were reviewed to collect and analyze epidemiological data, underlying etiologies, imaging work-up for diagnosis and management. Aneurysms were defined as fusiform or saccular enlargement of the portal venous vein or its branches, superior mesenteric vein and splenic vein. RESULTS: A total of 16 splanchnic vein aneurysms were identified. Four patients had portal venous hypertension. The imaging work-up was variable and included mainly non-invasive modalities (US: 8 patients; CTA: 8 patients and MRA: 9 patients) and conventional angiography in 2 patients. Eight aneurysms involved the portal vein (50%), 5 the splenic vein (31.3%), and 3 the superior mesenteric vein (18.7%). None of the patients underwent surgical or endovascular management. Imaging follow-up was performed in 12 patients, with no interval change over time with up to 10 years follow-up. CONCLUSION: In our series, the portal vein was most frequently involved. Diagnosis was exclusively based on imaging and management was limited to follow-up.

[Value of double reading of whole body CT in polytrauma patients]. / Intérêt de la double lecture du scanner corps entier dans la prise en charge des polytraumatisés.

PURPOSE: To assess the value of standard double reading of whole body CT in the management of polytrauma patients. MATERIALS AND METHODS: Prospective study between January and July 2005. Two senior radiologists with expertise in trauma imaging, blinded to clinical findings, reviewed 105 initial CT examinations of polytrauma patients. These examinations had initially been interpreted by the on-call radiologist. The second interpretations were performed within 12 hours of admission, and were considered the gold standard. RESULTS: A total of 105 patients were included with 82 males (78%) and 23 females (22%), aged between 2 and 83 years. The level of admission was graded III (n=64), II (n=30) and I (n=11). The second reading identified 3 lesions that were not initially described, each requiring a change in management, including splenic rupture (n=1), thoracic spine fracture (n=1) and epidural hematoma (n=1), with no unfavorable impact on mortality. Additional errors in the initial interpretation were identified: peripheral fractures (n=38), chest (n=36), brain (n=31), abdominal (n=28), spine (n=19) and maxillofacial (17) lesions and contrast extravasation (n=6). CONCLUSION: Based on the large number and severity of some lesions missed at initial interpretation of whole body CT of polytrauma patients, we recommend standard double reading of these examinations.

Multimodal imaging for the detection and characterization of liver lesions in a mouse model of neuroendocrine tumor.

BACKGROUND: The aim of this study was to compare in vivo magnetic resonance imaging (MRI) and ex vivo autoradiography with histopathological results for the detection and characterization of liver lesions in an experimental model of human neuroendocrine tumors. MATERIAL AND METHODS: Intestinal STC-1 endocrine tumor cells were injected into 30 nude mice to achieve hepatic dissemination. Seven to 30 days after injection, T2-weighted in vivo images covering the entire liver were acquired with a 7-T system. Autoradiographs were also obtained in 28 mice after injection of fluorodeoxyglucose (18F-FDG). The autoradiographic liver samples were then stained with an antichromogranin antibody before histological analysis. Tumor size and the hepatic tumor fraction were measured using the three imaging modalities. RESULTS: Metastatic tumors visualized on the histological liver sections ranged in size from 50 microm (day 7) to 3 mm (day 30). The hepatic tumor fraction increased with time, reaching 30% of the hepatic surface area on day 30. Visual analysis revealed variable tumor distribution and type (solid and/or cystic). On MRI, lesions were identified from day 12 (about 100 icrom in diameter) and the hepatic tumor fraction was up to 48% at day 30. The smallest lesions (350 microm in diameter) were also detected at day 12 on the autoradiographs. There was good correlation between tumor fractions determined from autoradiographic and histological data. CONCLUSION: In vivo, MRI appears to be well suited to the follow-up of liver lesions in a mouse model of neuroendocrine tumor. Preliminary results using 18F-FDG in this animal model are promising, showing differences in FDG uptake.

A magnetic resonance elastography (MRE) approach for liver investigation.

Due to its key role in carbohydrate metabolisation, blood detoxification, filtering and substance storing, liver is prone to a wide variety of diseases: hepatitis, cirrhosis, cancer. As such, liver investigation is a major field of interest. We describe here a non invasive way to obtain important information on liver elasticity properties. In vitro Magnetic Resonance Elastography (MRE) experiments are realized using a normalized substance (Agar gel in different concentrations) and this technique is also demonstrated in the context of an in vivo investigation of the elastic properties of a normal control liver.

Characterization of neuro-endocrine tumors in an athymic nude mouse model using dedicated synchronization strategies for T2-weigted MR imaging at 7T.

Endocrine tumours, with digestive localization, are tumours with variable forecast which are independent of their invasive and metastatic extensions. The experimental model of endocrine tumors with liver dissemination is available for evaluation of new medical therapeutics such as antiangiogenic therapy. MRI is a non invasive modality allowing in vivo examinations and is suitable to follow liver lesion evolution during longitudinal study on animal models. The goal of this study was to assess the detection level and to characterize the liver lesions in an athymic nude mouse model, using a dedicated MRI protocol and an optimized synchronization strategy at high magnetic field strength. The experiments were performed at 7T. To detect liver lesions, respiratory-triggered T2-weighted MR images is the sequence of choice. With conventional acquisition strategies used on small animal MR systems, trigger signal is performed at each respiratory cycle and thus, the T2 contrast is not freely controlled. Additionally, the slice number is limited by the expiration delay. To overcome these drawbacks, we proposed an original strategy enabling true T2-weighted imaging with minimal movement artifacts, regardless of the respiratory period and the number of slices. This protocol was used to carry out a longitudinal follow-up of hepatic lesions in 8 nude mice at stages D7, D12, D17 and D24. The fraction of lesion over the total liver volume was quantified. Moreover, the characterization of cystic or non-cystic type of lesions was achieved using various TE leading to T2 maps. In conclusion, the level of lesion detection and characterization of liver lesions was performed using a devoted protocol with original synchronization strategy dedicated to high field MRI. MR imaging could be used with relevance in the evaluation of new therapeutics protocol for treatment of liver lesions in neuroendocrine tumors using small animal model.

[Radiological management of vascular lesions secondary to pelvic injuries]. / Prise en charge radiologique des lésions vasculaires secondaires aux traumatismes du bassin.

Pelvic injuries are serious, with mortality higher than 40% if the patient is in shock upon arrival at the hospital. These injuries are generally secondary to traffic accidents with violent kinetics, which explains the frequency of the associated extrapelvic lesions. With the vital prognosis at stake, management of these patients is a true challenge from both the radiographic and emergency care points of view. The objectives of this review are to present the epidemiological and physiological issues involved in pelvic injuries and the place of imaging today, necessarily integrated within a multidisciplinary team associating emergency physicians, surgeons, radiologists, and biologists.

[Value of MRCP with Mangafodipir Trisodium (Teslascan) injection in the diagnosis and management of bile leaks]. / Intérêt de la cholangio-IRM avec perfusion de Mangafodipir Trisodium (Teslascan) dans le diagnostic topographique et la prise en charge des fuites biliaires.

PURPOSE: To assess the value of MRCP with Mangafodipir Trisodium (Teslascan) injection in the diagnosis and management of bile leaks. PATIENTS AND METHODS: Retrospective study of 25 patients (18 males, 7 females) with a mean age of 49.7 years and high clinical suspicion of bile leak who underwent MRCP with Mangafodipir Trisodium (Teslascan) injection between 2002 and 2006. The suspected etiology for bile leak was surgical (n=17), traumatic (n=7) or medical (n=1). The clinical suspicion was based on a combination of clinical, laboratory and imaging findings. RESULTS: MRCP with Teslascan injection demonstrated a bile leak in 20 patients. The site of leak was depicted in 17 cases: second order of smaller bile duct, (n=9), hepatic duct (n=3), confluence (n=2), cystic duct (n=1), bilioenteric anastomosis (n=2). Management based on MR findings included biloma drainage (n=7), biliary drainage (n=5), endoscopic management (n=2), repeat surgery (n=3), expectant management (n=1), and medical management (n=1). Outcome was favourable in 18 cases. Two patients died from infectious complications. CONCLUSION: In addition to confirming a diagnosis of bile leak, MRCP with Teslascan injection depicts the site of leak allowing optimal management.

Synchronisation strategies in T2-weighted MR imaging for detection of liver lesions: Application on a nude mouse model.

AIM: The objective of this work was to propose original synchronisation strategies based on T2-weighted sequence performed on a small animal MRI spectrometer in order to improve the image contrast and detect mouse liver lesions at high magnetic field. MATERIALS AND METHODS: The experiments were performed in vivo at 7T using a 32 mm inner diameter cylindrical volumetric coil for both RF emission and reception. A sensitive pressure sensor was used to detect external movements due to both respiration and heart beats. The pressure sensor was interfaced with a commercial ECG Trigger Unit to use dedicated functionalities (trigger levels, delays and window). To enable T2-weighted imaging with minimised T1 effects, an acquisition strategy with controlled TR spanning over several respiratory cycles was developed. With this strategy, the slices were acquired over several respiratory periods. RESULTS: The acquisition, performed over several respiratory periods, enables a longer TR than the typical mouse respiratory period. The image contrast is controllable and independent of the respiratory period. The heavily T2-weighted images obtained with the developed strategy allow better visualisation of lesions at high magnetic field. Moreover, double respiratory and cardiac synchronisation, based on a unique sensitive pressure sensor, improves image quality with less motion artifacts, especially in the ventral liver region. The total slice number is independent of respiratory period and thin slices can be acquired to cover the whole liver. CONCLUSION: The developed strategy enables high quality pure T2-weighted imaging with minimal motion artifacts. This strategy improves T2-weighted image contrast and quality, especially at high magnetic field, on animals with short respiratory periods. The strategy was demonstrated using a mouse model of liver lesions at 7T. This protocol could be used to carry out a longitudinal follow-up.

[Out of phase magnetic resonance imaging and liver applications]. / Imagerie par résonance magnétique en opposition de phase et ses applications hépatiques.

The increasing indications for MRI evaluation of diseases of the abdomen, especially liver tumors, has promoted the development of sequences allowing further histological characterization. Out of phase sequences provide suppression of lipids and water signal at the cellular level. Available on all MR imagers, it is the most sensitive sequence to depict small amounts of lipids in the liver. Best applications of this sequence include liver steatosis, tumoral characterization with regards to lipid content (adenoma, hepatocellular carcinoma...) and depiction of tumors in abnormal liver. Performed without contrast injection, and using fast imaging acquisition, we believe that out of phase imaging should be performed for magnetic resonance imaging of the liver.