Radiofrequency ablation versus surgical resection for the treatment of oligometastatic lung disease.

PURPOSE: The purpose of this study was to compare efficacy and tolerance between radiofrequency ablation (RFA) and surgery for the treatment of oligometastatic lung disease. MATERIALS AND METHODS: This retrospective study reviewed patients treated in two institutions for up to 5 pulmonary metastases with a maximal diameter of 4cm and without associated pleural involvement or thoracic lymphadenopathy. Patient demographics, tumor characteristics, treatment outcome, and length of hospital stay were compared between the two groups. Efficacy endpoints were overall survival (OS), progression-free survival (PFS) and pulmonary or local tumor progression rates. RESULTS: Among 204 patients identified, 78 patients (42 men, 36 women; mean age, 53.3±14.9 [SD]; age range: 15-81 years) were treated surgically, while 126 patients (59 men, 67 women; mean age, 62.2±10.8 [SD]; age range: 33-80 years) were treated by RFA. In the RFA cohort, patients were significantly older (P<0.0001), with more extra-thoracic localisation (P=0.015) and bilateral tumour burden (P=0.0014). In comparison between surgery and RFA cohorts, respectively, the 1- and 3-year OS were 94.8 and 67.2% vs. 94 and 72.1% (P=0.46), the 1- and 3-year PFS were 49.4% and 26.1% vs. 38.9% and 14.8% (P=0.12), the pulmonary progression rates were 39.1% and 56% vs. 41.2% and 65.3% (P>0.99), and the local tumour progression rates were 5.4% and 10.6% vs. 4.8% and 18.6% (P=0.07). Tumour size>2cm was associated with a significantly higher local tumor progression in the RFA group (P=0.010). Hospitalisation stay was significantly shorter in the RFA group (median of 3 days; IQR=2 days; range: 2-12 days) than in the surgery group (median of 9 days; IQR=2 days; range: 6-21 days) (P<0.01). CONCLUSION: RFA should be considered a minimally-invasive alternative with similar OS and PFS to surgery in the treatment of solitary or multiple lung metastases measuring less than 4cm in diameter without associated pleural involvement or thoracic lymphadenopathy.

Percutaneous thermal ablation: A new treatment line in the multidisciplinary management of metastatic leiomyosarcoma?

BACKGROUND: The role of percutaneous thermal ablation (PTA) in the multidisciplinary management of metastatic leiomyosarcoma (LMS) has not been thoroughly evaluated. MATERIALS AND METHODS: Single institution retrospective review of all patients with LMS metastases treated with PTA from June 2004 to December 2014. Iterative PTAs were performed as a multifocal treatment for all recurrent or residual macroscopic metastases discovered on imaging after completion of systemic treatment, or alternatively as a targeted treatment of selective metastases found to be progressive on systemic treatment. The primary endpoint was the time to untreatable progression (TTUP), recorded as the time elapsed between the first PTA and the re-initiation of systemic chemotherapy to treat disease progression. Secondary endpoints were overall survival, the 1, 3 and 5-year survival rates, and local control rate. RESULTS: A total of 93 LMS metastases (average diameter 18.2 mm, range 3-45 mm) were successfully treated in 30 patients over 50 treatment sessions with a median follow-up of 34.6 months. The median TTUP was 14.2 months (range 2.4-122.8). The median overall survival after PTA was 48.3 months and the 1, 3 and 5-year overall survival rates were 96.7% (95%CI 84.3-100.0%), 62.0% (95%CI 45.8-84.0%), and 28.3% (95%CI 13.5-59.1%) respectively. Local control rate at 1 year was 95.2% and at 3 years was 89.4%. CONCLUSION: Iterative PTA is an effective treatment line option for appropriately selected patients with metastatic LMS that can delay re-initiation of systemic chemotherapy.

Peripherally inserted central catheter placement in patients with coagulation disorders: A retrospective analysis.

OBJECTIVE: To assess the safety of peripherally inserted central venous catheter (PICC) placement in patients with altered and uncorrected coagulation parameters or receiving antiplatelet therapy. MATERIALS AND METHODS: Medical charts of all patients with major primary and secondary hemostasis disorders, combined hemostasis disorders or on antiplatelet therapy and who had undergone non-tunneled PICC placement from December 2009 to December 2013, were retrospectively reviewed. A hemostatic disorder was defined as a platelet count (PC)≤50×10(9)/L, an international normalized ratio (INR) ≥ 2, or an activated partial thromboplastin time (aPTT)≥66s, alone or in combination. Underlying hemostasis disorders were not corrected and antiplatelet therapy was not interrupted before PICC placement in any patient. 4, and 5-Fr single and dual lumen PICCs were used. RESULTS: A total of 378 PICCs were placed in 271 patients (180 men and 91 women; mean age=62±13.4years; range, 18-93 years)) with coagulation disorders. Eighty-nine (23%) PICCs were placed in patients who were receiving antiplatelet therapy (aspirin, clopidogrel, rivaroxaban). Thrombocytopenia was noted in 269PICC placements (71%). Among these patients, 23 had disseminated intravascular coagulation. Prolonged INR and aPTT were observed in 42 procedures (11.1%). PICC placement was achieved in all patients, with a mean number of 1.14 attempts. Peripheral venous access was obtained through the basilic and the brachial vein respectively in 295 (79.1%) and 83 (20.9%) of patients. The placements were performed by residents and fellows in 108 (28.5%) and 270 (71.5%) procedures, respectively. No early or late complications were reported after any procedure. No accidental puncture of the brachial artery occurred. CONCLUSION: In patients with severe primary and secondary hemostasis disorders, combined hemostasis disorders or on antiplatelet therapy, PICC placement is a feasible and safe procedure and does not require correction of coagulation parameters or discontinuation of antiplatelet therapy.

Thermal ablation techniques: a curative treatment of bone metastases in selected patients?

INTRODUCTION: Thermal ablation techniques (radiofrequency-ablation/cryotherapy) can be indicated with a curative intent. The success rate and prognostic factors for complete treatment were analysed. MATERIAL/METHODS: The medical records of all patients who had undergone curatively intended thermal ablation of bone metastases between September 2001 and February 2012 were retrospectively analysed. The goal was to achieve complete treatment of all bone metastases in patients with oligometastatic disease (group 1) or only of bone metastases that could potentially lead to skeletal-related events in patients with a long life expectancy (group 2). We report the rate of complete treatment according to patient characteristics, primary tumour site, bone metastasis characteristics, radiofrequency ablation/cryotherapy and the treatment group (group 1/group 2). RESULTS: Eighty-nine consecutive patients had undergone curatively intended thermal ablation of 122 bone metastases. The median follow-up was 22.8 months [IQR = 12.2-44.4]. In the intent-to-treat analysis, the 1-year complete treatment rate was 67% (95%CI: 50%-76%). In the multivariate analysis the favourable prognostic factors for complete local treatment were oligometastatic status (p = 0.02), metachronous (p = 0.004) and small-sized (p = 0.001) bone metastases, without cortical bone erosion (p = 0.01) or neurological structures in the vicinity (p = 0.002). CONCLUSION: Thermal ablation should be included in the therapeutic arsenal for the cure of bone metastases. KEY POINTS: • Thermal ablation techniques are currently performed to palliate pain caused by bone metastases. • In selected patients, thermal ablation can also be indicated with a curative intent. • Oligometastatic and/or metachronous diseases are good prognostic factors for local success. • Small-size (<2 cm) bone metastases and no cortical erosion are good prognostic factors.

MRI assessment of local acute radiation syndrome.

OBJECTIVES: To describe local acute radiation syndrome and its radiological imaging characteristics. METHODS: We performed a retrospective study of patients who had suffered skin and deeper radiation damage who were investigated by magnetic resonance imaging (MRI). We compared the clinical findings, C-reactive protein (CRP) levels and MRI results. RESULTS: A total of 22 MRI examinations were performed between 2005 and 2010 in 7 patients; 6 patients had increased CRP levels and MRI abnormalities. They were treated by surgery and local cellular therapy. One patient had no CRP or MRI abnormalities, and had a spontaneous good outcome. Eighteen abnormal MR examinations demonstrated high STIR signal and/or abnormal enhancement in the dermis and muscle tissues. Three MRI examinations demonstrated skeletal abnormalities, consistent with radionecrosis. The four normal MRI examinations were associated only with minor clinical manifestations such as pain and pigmentation disorders. CONCLUSION: MRI seems to be a useful and promising imaging investigation in radiation burns management i.e. initial lesion evaluation, treatment evaluation and complication diagnosis. MRI findings correlated perfectly with clinical stage and no false negative examinations were obtained. In particular, the association between normal MRI and low CRP level seems to be related to good outcome without specific treatment. KEY POINTS: Local acute radiation syndrome (radioepidermitis) mainly affects the skin and superficial tissues. MRI findings correspond with clinical stage (with a strong negative predictive value). MRI outperformed X-ray examination for the diagnosis of bone radionecrosis. Diffusion-weighted imaging shows low ADC in bone and soft tissue necrosis. Perfusion sequence allows assessment of tissue microcirculation impairment.

Gadolinium enhancement in brain magnetic resonance imaging in progressive multifocal leukoencephalopathy after natalizumab monotherapy: is it really atypical?

Progressive multifocal leukoencephalopathy (PML) generally occurs in patients with impaired cellular immunity. Monoclonal antibodies also predispose the patient to PML as they depress the immune system. PML was classically characterized by a lack of inflammation and absence of gadolinium enhancement. However, gadolinium enhancement of PML lesions was first described in HIV-positive patients under therapy. We present a case of gadolinium enhanced PML lesions occuring after natalizumab monotherapy of a relapsing multiple sclerosis. Radiologists must be aware of this particular feature, as confirmation of the diagnostic of PML becomes more challenging. Namely, distinction between starting PML and multiple sclerosis enhanced additional active lesion is difficult and diagnosis must be established by combined analysis of full clinical evolution, brain MRI scans, and polymerase chain reaction of cerebrospinal fluid.

[Periprocedural management of hemostasis risk in interventional radiology]. / Prise en charge du risque hémostatique au cours des actes de radiologie interventionnelle.

Given the increasing demand for interventional image-guided procedures, radiologists are increasingly sollicited by clinicians to participate in the management of patients prior to and after the interventional procedure, especially with regards to hemostasis. Therefore, radiologists should be familiar with the risk of procedure related hemorrhage. Based on consensus guidelines published by the Society of Interventional Radiology (SIR), the risk of hemorrhage for each interventional procedure will be classified. Recommendations for preprocedure testing based on the type of procedure planned will be reviewed. Finally, limitations of hemostasis parameters will be discussed along with management of anticoagulants and antiplatelet agents before the procedure.

[Management of pulmonary masses by guided transthoracic fine needle biopsy under computed tomography. Contribution from the Pathology and Radiology Departments of the Percy Military Hospital (Clamart, France) over 10 years]. / Prise en charge des ponction-biopsies guidées sous tomodensitométrie des masses pulmonaires. Contribution de la radiologie et de l'anatomie pathologique à l'Hôpital d'instruction des Armées Percy sur dix ans.

Examining 260 samples of pulmonary nodules obtained by percutaneous biopsy under tomodensitometric control from the departments of radiology and pathology over 10 years, the authors note the advantages and disadvantages of this technique, provide the results of their experience and emphasise the importance of these biopsies in malignant pathology. The results of this series can be superposed with those found in the literature. Malignant tumours account for 75 % of the cases, with a clear prevalence of primitive adenocarcinoma. Benign pathology (approximately, 14 % of the cases) was represented by necrosis without any specificity, fibrous reaction and infectious causes. The act had to be repeated for the false negatives (7 %).

[Rhinocerebral infections in immunosuppressed patients with hematological disorders]. / Infections rhinocérébrales chez l'immunodéprimé en hématologie.

Invasive rhinosinusitis, occurring almost exclusively in immunosuppressed patients, is defined by the presence of local inflammation with vascular and osseous necrosis with extensive soft tissue extension. Imaging and bacteriological and even histological (mycelial filaments) criteria have been established. Because it can evolve to death in patients with hematological disorders, accurate diagnosis is important but difficult to achieve due to the non-specific nature of signs and symptoms. Imaging plays an important role with CT of the paranasal sinuses and MR imaging of the brain for early diagnosis and treatment in order to improve prognosis. We will present the imaging features of three cases of rhinocerebral infections, with two cases of fungal infection and one case of invasive bacterial sinus infection.

[An unusual MRI observation of neurosarcoidosis]. / A propos d'une observation singulière de neurosarcoïdose.

Sarcoidosis is a multisystemic granulomatous disease, characterized by the formation of an inflammatory lesion, the noncaseating giant-cell granuloma. Neurosarcoidosis represents only 5% of cases, but this figure is probably an underestimation. Diagnosis is difficult because of its clinical and radiological polymorphism. Magnetic resonance imaging (MRI) represents the "gold standard" of central nervous system exploration. We report here on an atypical example of primary neurosarcoidosis, according to MRI semiology, with preferential involvement of the Virchow-Robin perivascular spaces.

[A rare cause of epigastric pain: isolated spontaneous dissection of the celiac artery, a case report]. / Une cause rare de douleur épigastrique: la dissection spontanée isolée du tronc coeliaque, à propos d'un cas.

Spontaneous dissection of visceral arteries, and more particularly of the celiac artery, is a rare event. We report an exceptional case of an isolated spontaneous dissection of the celiac artery which occurred in a 53-year-old man seen in an emergency setting for suspected acute pancreatitis. Computed tomography enabled the diagnosis, revealing spontaneous isolated dissection of the celiac artery, associated with a small aneurysmal dilatation of the artery. Based on a review of the literature and this clinical experience, we recall the contribution of computed tomography and 3D reconstructions to the diagnosis, the therapeutic strategy and the follow-up of spontaneous dissection of visceral arteries.

[Late mediastinal metastasis of Ewing's sarcoma of tibia]. / Métastase médiastinale tardive d'un sarcome d'Ewing du tibia.

Peripheral neuroectodermal tumors constitute a large spectrum of small round cell tumors among which Ewing's sarcoma is the most undifferentiated type. They are rare tumors which often concern young people and generally occur in bone tissue. Their metastatic potential is high, generally early, and rarely after five years. We report the case of a 45-year-old woman who presented a mediastinal metastasis eight years after the primitive tumor of tibia. The diagnosis was made on small core biopsies obtained by CT punction, and was based on morphologic analysis, immunohistochemistry, and confirmed by molecular biology. The presence of metastasis is the main prognostic factor. Despite therapeutic progress, the global survival rate of metastatic patients is still poor.

[Subtle brain abnormalities in adrenomyeloneuropathy]. / Anomalies cérébrales subtiles de l'Adrénomyéloneuropathie.

PURPOSE: To describe subtle brain abnormalities detected on MRI in adult patients with adrenomyeloneuropathy (AMN). Materials and methods. Retrospective evaluation of data acquired prospectively as part of a clinical trial (Riluzole) in 66 adult patients with AMN without obvious brain lesion on MR. All patients underwent brain MR including T1W, T2W, FLAIR and spectroscopy. After a review had been validated by three different reviewers, review of MR images was performed by consensus using a semi-quantitative scale. RESULTS: Preliminary analysis of MR images confirmed the presence of signal abnormalities involving the corticospinal tracts in 36 patients (54.6%). Additional subtle abnormalities were also detected: white matter palor, mainly parieto-occipital in location, with patchy hyperintensity in 36 patients (54.6%), hyperintense pontocerebellar fibers on T2W and FLAIR in 25 patients (41.7%). The presence of elevated Cho/Cr and mI/Cr ratios, described in the literature, were confirmed. CONCLUSION: This retrospective study allows the description of an AMN pattern on MRI in patients without white matter or callosal abnormalities.

Merkel cell tumor: report of two cases and review of the literature.

The "Merkel cell carcinoma" is a rare tumor usually occuring in the sun-exposed skin. Its poor prognosis is explained by a high rate of metastasis (one third of the patients at the initial presentation) and a high post-operative recurrence rate. Descriptions of the imaging features of this type of tumor are rare. We present two cases of Merkel cell carcinoma localized to the head region. In the first patient, the lesion involved the soft tissues of the scalp with secondary invasion of the skull and meninges. The second patient had a metastasis to the parietal lobe.