[Can preoperative prostate MRI before radical prostatectomy predict extracapsular extension and the side of the index lesion?]. / L'IRM de la prostate préopératoire avant prostatectomie radicale peut-elle prédire l'extension extracapsulaire et le côté de la lésion de référence?

AIM: To evaluate the role of preoperative multi-parametric magnetic resonance imaging (MP-MRI) in patients undergoing radical prostatectomy. Specifically, the accuracy of MP-MRI in detecting extracapsular extension (ECE) and individuating the side of the index lesion have been explored. METHODS: Thirty-five consecutive patients undergoing radical prostatectomy have been retrospectively analyzed. The MRI exam incorporated T2-weighted imaging, diffusion-weighted imaging and dynamic contrast enhancement in all patients. χ(2) test was performed to assess an association between an MP-MRI suggestive of ECE and pathologic ECE; similar tests were performed to study the association between the MRI-detected side of the index lesion and its true localization on final pathology. Univariate logistic regression models were constructed to evaluate possible predictors of ECE, including MP-MRI suspected ECE. RESULTS: Seventeen percent (6/35) of men presented ECE on final pathology. MP-MRI was predictive of pathologic ECE with a negative predictive value and specificity of 93% and 90%, respectively. Global accuracy of MP-MRI in predicting ECE was 86%. MRI-detected ECE was significantly predictive of pathologic ECE on logistic regression (OR: 17.3, 95% CI: 2.2-138.2, P=0.007). Moreover, MRI significantly predicted the side of the index lesion (P=0.012). CONCLUSIONS: In this single center cohort, preoperative MP-MRI was significantly predictive of ECE and side of the index lesion. Further studies are necessary to individuate patients who can benefit from preoperative MP-MRI. LEVEL OF EVIDENCE: 5.

Radiofrequency interstitial tumor ablation (RITA) is a possible new modality for treatment of renal cancer: ex vivo and in vivo experience.

Small renal tumors are increasingly diagnosed and are frequently treated by nephron-sparing surgery. Tumors can be ablated by radiofrequency (RF) energy, which allows the operator to create very localized necrotic lesions. Radiofrequency interstitial tumor ablation (RITA) has been used in human kidneys in an ex vivo experiment to assess the necrotic lesions produced in a model close to physiologic conditions and then in three patients with localized renal cancer prior to radical nephrectomy. In the ex vivo model, four freshly removed kidneys were treated. Bipolar RF energy was delivered by a generator connected to two needles introduced parallel to each other into the renal parenchyma. A thermocouple was inserted between the two active electrodes. The renal artery at physiologic conditions was maintained at a constant temperature of perfusion of 37 degrees C by a computer-assisted Hot-line monitor. Two lesions were produced in each pole of each kidney including the cortex and the medulla. In an initial human study focusing on safety, feasibility, and pathology, three patients were treated by RITA with bipolar and monopolar energy. One patient with a peripheral 2-cm upper-pole tumor was treated percutaneously under ultrasound guidance with local anesthesia only 1 week prior to surgery. The other patients, with 3- and 5-cm tumors, were treated during surgery under general anesthesia just before nephrectomy. Ex vivo, the maximum temperature at the active needles ranged from 84 degrees C to 130 degrees C with 10 to 14 W applied during 10 to 14 minutes. Lesions were on average 2.2 x 3 x 2.5 cm.3 Microscopic examination showed stromal edema with intensive pyknosis. No damage was seen to adjacent untreated tissue. In the in vivo procedure, tolerance of RTA as an anesthesia-free procedure was excellent. The size of the observed lesions was comparable to the forecast size depending on the needle deployment. No side effects were noted, and no adjacent structures were affected by the RF ablation. These preliminary studies demonstrate the ability of RITA to produce localized extensive necrosis in kidney parenchyma and tumors safely under local anesthesia. Further studies could evaluate this new minimally invasive treatment in small kidney tumors considered for nephron-sparing surgery.

Neoadjuvant hormonal treatment prior to radical prostatectomy: facts and open questions.

Since the advent of reversible androgen deprivation, its use for a short period of time (usually 3 months) before radical prostatectomy has been advocated by an increasing number of urologists without clear and definitive proof of its advantage. Most authors have demonstrated downsizing of the prostate by some 30-50%. Clinical downstaging was demonstrated in about 30% but this could not be confirmed at final pathological staging although downgrading was noted in some 10% of the series analyzed. Reduction of positive margins in patients receiving neoadjuvant treatment varies between 15% and 25% compared to control group. Several biases may however complicate the analysis of these results, the main cause of misinterpretation being the difficulty encountered by the pathologist to properly grade and score the tumor after hormonal deprivation. Even if some early significant advantages can be observed such as a decrease of positive margins and anecdotal complete disappearance of tumor in some specimens, this may not necessarily alter the metastatic spread and the overall survival rate. Only long follow-up in large prospective randomized studies evaluating biological (PSA) and clinical failures, time to progression and survival will allow definitive conclusions on this still controversial approach.

[Urinary lithiasis: epidemiology and physiopathology]. / Lithiase urinaire: épidemiologie et physiopathologie.

Urolithiasis has an incidence of about 12% in men and about 5% in women before the age of 70 years. Several epidemiological factors are involved in the predisposition to the urinary stone disease, notably: age, sex, race, climate, geography, profession, social class, nutritional factors and inherent genetic particularities. A number of physicochemical mechanisms govern lithogenesis, passing from saturation and supersaturation of urine to nucleation, crystallization and crystal growth to clinically significant sizes when the inhibition mechanisms are overwhelmed or absent. Generally urinary stone are of diverse aetiologies, that can essentially be grouped in calcium, uric acid, cystine and magnesium ammonium phosphate stones with subgroups in relation to the varied pathophysiological mechanisms involved in each case.

[Diagnostic approaches in calculi]. / Approche diagnostique des lithiases.

Diagnosis of the stone is based on anamnesis, physical examination and radiological investigation. Anamnesis and physical examination need to be supported by knowledge of the neuroanatomy of the urinary upper tract. Radiological investigation should be both non toxic and effective. Gold standard radiological examination in the evolution of urolithiasis remains the echography. Urography leads to be replaced by helical scanner less toxic and more efficient. This review tries to present the different possibilities of investigations in the diagnosis of urolithiasis.

[A metabolic approach to patients with calculi]. / Approche métabolique du patient lithiasique.

Metabolic evaluation remains cornerstones in the treatment and prevention of recurrence in patients with urolithiasis. The various chrystallographic, biological and radiological investigation should be done only in patients presenting recurrence and/or given risks factor of recurrences. The choice of the investigation is guided by the knowledge of the pathophysiological phenomena and should thus be adapted to each patient. Results should be analyzed by a multidisciplinary team. This aspect will be developed in the next paragraph.

[Predictive value of the serum PSA level in patients having undergone neo-adjuvant hormone treatment before radical prostatectomy]. / Valeur prédictive du taux sérique de PSA chez des patients ayant bénéficié d'un traitement hormonal néo-adjuvant avant prostatectomie radicale.

Great interest has been generated recently in preoperative androgen deprivation for clinical stage B ou C (T2 ou T3) prostate cancer. The influence of neoadjuvant hormonal therapy on down-staging and down-grading is still controversial. To assess the influence of preoperative androgen deprivation on serum PSA levels, we compared pre- and post-treatment serum PSA levels in 54 patients who received complete pre-operative androgen blockade (LHRH agonist + flutamide) 3 months prior to surgery. All patients with a pretreatment PSA > 20 ng/ml had extra-prostatic disease excepted two patients who presented lesions of acute prostatitis with adenocarcinoma. After hormonal deprivation, 51/54 patients experienced a return of PSA to normal values (< 4 ng/ml). Among this patient, 33 had undetectable PSA levels (< 0.25 ng/ml). 90% of the patients with undetectable had tumor confined to the gland (pT2/B). On the other hand, patients who still have PSA > 4 ng/ml after hormonal deprivation, had extra-prostatic cancer (pT3-pT4). Thus, PSA levels after 3 months neo-adjuvant hormonal treatment might have a useful predictive value in patients selection for radical surgery.

Elevated CEA in breast cancer patients with overlooked medullary thyroid carcinoma.

After mastectomy and radiation for breast cancer, two patients were found to have persistent elevated CEA in their serum. This finding was erroneously attributed to occult metastases for the first patient and to local recurrence for the second. Overlooked medullary thyroid carcinoma (MTC) was the causal disease in both patients. A review of the literature stresses the frequency of CEA elevation in serum of MTC patients. A thorough search for any possible cause of elevated levels of CEA is advocated, particularly by thyroid sonogram with a needle aspiration biopsy when a nodule is discovered and by calcitonin assay in the serum.