Salvage Percutaneous Cryoablation for Bleeding Upper Tract Urothelial Carcinoma.

PURPOSE: Endoscopic access and treatment of bleeding upper urinary tract urothelial carcinomas (UTUCS) is sometimes difficult and inefficient as resection and/or laser coagulation are often incomplete. We report two cases of successful cryoablation of bleeding UTUCs. MATERIALS AND METHODS: This study evaluated an adjunctive method in using cryoablation as a hemostatic technique. Cryoprobes were inserted inside the affected calices and a standard renal cryoablation protocol was used. Track ablation was performed during the pullback of the cryoprobes to prevent tumor seeding and bleeding. RESULTS: Cryoablation of the bleeding upper urinary tract tumors allowed to efficiently resolve macrohematuria in both patients and to provide prolonged remission in one patient. CONCLUSIONS: Taking advantage of the microcirculatory stasis and the hemostatic properties of cryoablation, we achieved palliative cessation of refractory macrohematuria while sparing nephrons, without the need for renal embolization in patients with bleeding UTUCs.

Image-guided lymph node core-needle biopsy predicts survival in mycosis fungoides and Sézary syndrome.

BACKGROUND: The prognosis of Sézary syndrome (SS) and mycosis fungoides (MF) depends on lymph node (LN) involvement. The usefulness of LN image-guided core-needle biopsies (CNBs), instead of surgical sampling, has been poorly evaluated. OBJECTIVES: To determine the prognostic value of LN CNB in MF/SS. METHODS: A retrospective search was conducted to identify all LN biopsy specimens of MF/SS between 2008 and 2019. Biopsies were staged according to the International Society for Cutaneous Lymphomas/European Organisation for Research and Treatment of Cancer (ISCL/EORTC) criteria. We performed immunolabelling and determined the tumour clone frequency (TCF) by high-throughput sequencing of the T-cell receptor beta locus. RESULTS: We included 119 consecutive biopsies from 100 patients, 45 with MF and 55 with SS. N1, N2 and N3 stages were diagnosed in 34 (29%), 26 (22%) and 59 (49%) cases, respectively. The TCF, Ki67 index, and percentage of cells positive for thymocyte selection-associated high mobility group box protein (TOX), programmed cell death protein 1 (PD1), killer cell immunoglobulin-like receptor 3DL2 (KIR3DL2) and cluster of differentiation (CD)30 were all positively correlated with the N stage. Median overall survival (OS) for N1/N2 vs. N3 patients was 42 months (range 26-not reached) vs. 14 months (range 5-30), respectively (P < 0·001). In univariate analyses, an age > 75 years, LN short-axis diameter > 15 mm, N3 stage, presence of large-cell transformation, TOX > 60%, PD1 > 25%, Ki67 > 30%, KIR3DL2 > 15%, CD30 > 10% and TCF > 25% were identified as adverse prognostic factors. In multivariate analyses, only an age > 75 years and Ki67 index > 30% were associated with reduced OS. We developed a new prognostic index associating the N stage and the Ki67 index, which better discriminates N3 patients with poor prognosis. CONCLUSIONS: CNB allows an objective assessment of the LN involvement in MF/SS, relevant for staging and prognosis.

Interventional oncology at the time of COVID-19 pandemic: Problems and solutions.

The COVID-19 pandemic has deeply impacted the activity of interventional oncology in hospitals and cancer centers. In this review based on official recommendations of different international societies, but also on local solutions found in different expert large-volume centers, we discuss the changes that need to be done for the organization, safety, and patient management in interventional oncology. A literature review of potential solutions in a context of scarce anesthesiologic resources, limited staff and limited access to hospital beds are proposed and discussed based on the literature data.

Salvage cryoablation for local recurrence of prostatic cancer after curative therapy.

PURPOSE: The purpose of this study was to determine the efficacy of salvage cryotherapy for intra-prostatic and local extraprostatic recurrences after curative treatment of prostate adenocarcinoma. MATERIAL AND METHOD: Twenty-eight men (mean age, 69±6 [SD] years; range: 51-82 years) treated with cryoablation for prostatic (N=21) or extraprostatic (N=7) recurrent prostate cancer after radiotherapy with or without associated prostatectomy were included. Technical success, complication and recurrences were reported. Biological recurrence was defined as an elevation ≥2ng/mL of prostate specific antigen (PSA) serum level after the treatment. RESULTS: The mean follow-up was 18 months. Among the 21 patients with intraprostatic recurrence, 14 had successful cryotherapy with a mean decrease in serum prostate-specific antigen (PSA) levels of -5.7±2.6 (SD) ng/mL (range: -2.1 to -16.9ng/mL). Four patients (19%) had early progression and three patients (14%) had delayed biological recurrence (mean time: 15 months). Among the 7 patients with extraprostatic recurrence, 2/7 (291%) had successful cryotherapy with a decrease in PSA serum level of -2.7±1.6 (SD) ng/mL (range: -0.5--5.5ng/mL) and 4/7 (57%) had early biological recurrence after cryotherapy that required androgen deprivation therapy, whereas 1/7 (4%) was lost to follow-up. No major complications were observed for both intra- and extraprostatic recurrence. CONCLUSION: Salvage cryoablation of locally recurrent prostate cancer after curative treatment is feasible and safe when the half prostate is treated. It could delay initiation of androgen deprivation therapy in these patients.

Evaluation of the clinical benefit of an electromagnetic navigation system for CT-guided interventional radiology procedures in the thoraco-abdominal region compared with conventional CT guidance (CTNAV II): study protocol for a randomised controlled trial.

BACKGROUND: Interventional radiology includes a range of minimally invasive image-guided diagnostic and therapeutic procedures that have become routine clinical practice. Each procedure involves a percutaneous needle insertion, often guided using computed tomography (CT) because of its availability and usability. However, procedures remain complicated, in particular when an obstacle must be avoided, meaning that an oblique trajectory is required. Navigation systems track the operator's instruments, meaning the position and progression of the instruments are visualised in real time on the patient's images. A novel electromagnetic navigation system for CT-guided interventional procedures (IMACTIS-CT®) has been developed, and a previous clinical trial demonstrated improved needle placement accuracy in navigation-assisted procedures. In the present trial, we are evaluating the clinical benefit of the navigation system during the needle insertion step of CT-guided procedures in the thoraco-abdominal region. METHODS/DESIGN: This study is designed as an open, multicentre, prospective, randomised, controlled interventional clinical trial and is structured as a standard two-arm, parallel-design, individually randomised trial. A maximum of 500 patients will be enrolled. In the experimental arm (navigation system), the procedures are carried out using navigation assistance, and in the active comparator arm (CT), the procedures are carried out with conventional CT guidance. The randomisation is stratified by centre and by the expected difficulty of the procedure. The primary outcome of the trial is a combined criterion to assess the safety (number of serious adverse events), efficacy (number of targets reached) and performance (number of control scans acquired) of navigation-assisted, CT-guided procedures as evaluated by a blinded radiologist and confirmed by an expert committee in case of discordance. The secondary outcomes are (1) the duration of the procedure, (2) the satisfaction of the operator and (3) the irradiation dose delivered, with (4) subgroup analysis according to the expected difficulty of the procedure, as well as an evaluation of (5) the usability of the device. DISCUSSION: This trial addresses the lack of published high-level evidence studies in which navigation-assisted CT-guided interventional procedures are evaluated. This trial is important because it addresses the problems associated with conventional CT guidance and is particularly relevant because the number of interventional radiology procedures carried out in routine clinical practice is increasing. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01896219 . Registered on 5 July 2013.

Image-guided biopsy in primary lung cancer: Why, when and how.

Initial histopathological analysis of a pulmonary lesion is mandatory whenever a lung cancer is suspected in order to determine the optimal diagnostic strategy. Adequate material must be obtained for a definite histological diagnosis (preferable to a cytological one) and in some cases (mainly in adenocarcinoma) molecular analysis. The two main methods to obtain adequate biopsy samples are flexible bronchoscopy and computed tomography (CT)-guided lung biopsy. Flexible bronchoscopy is a valuable method for proximal tumors. On the other hand, CT-guided lung biopsy is more accurate for peripheral tumors. CT-guided lung biopsy is a reliable procedure that conveys a 90% sensitivity for the diagnosis of lung cancer. When performed in a secured environment after contraindications evaluation, its severe complications rate is low, mainly consisting of pneumothorax requiring chest tube placement and hemoptysis.

Diagnostic strategy for the assessment of axillary lymph node status in breast cancer.

The nodal status in breast cancer is a major prognostic factor in terms of survival. It also plays a role in the therapeutic decision-making process. Therefore, the evaluation of lymph node involvement in breast cancer is imperative in establishing a personalized treatment scheme. The sentinel lymph node procedure has proved successful for small breast tumors (T1-T2), limiting axillary lymphadenectomy and its side effects without changing overall survival. Even so, a substantial number of women must undergo axillary lymphadenectomy during a second surgery when the analysis of the sentinel node discloses major nodal involvement. Imaging can improve patient selection, especially those who appear eligible for immediate axillary lymphadenectomy. Ultrasound is able to depict morphological abnormalities in the lymph nodes such as cortical thickening, peripheral vascularization, hilar infiltration and loss of the kidney-shaped appearance of a normal node. When ultrasound is negative, the risk of massive nodal involvement is limited, thus allowing the oncologist to take an approach with the sentinel lymph node procedure. Magnetic resonance imaging (MRI) can also be useful in detecting pathological lymph nodes, particularly with diffusion-weighted MRI sequence.

Biopsies in oncology.

Imaging-guided percutaneous biopsies in patients in oncology provide an accurate diagnosis of malignant tumors. Percutaneous biopsy results are improved by correct use of sampling procedures. The risks of percutaneous biopsy are low and its complications are generally moderate. These risks can be reduced using aids such as blund tip introducers, hydrodissection and correct patient positioning. The multidisciplinary team meetings dialogue between oncologist, surgeon and radiologist correctly defines the indications in order to improve the treatment strategies.

Correlation between MRI and biopsies under second look ultrasound.

The term "second look" lesions in MRI refers to lesions detected by MRI that were not initially seen on mammography or ultrasound. The objectives of our study were to analyse the displacement of targets between MRI and ultrasound; to define discriminating BIRADS morphological criteria to predict benign or malignant character and better establish the indications of second look ultrasound and biopsy; and to analyse the agreement between ultrasound and MRI in terms of morphological criteria. A retrospective and monocentric review was performed of the records of consecutive patients with breast abnormalities (mass or non-mass) initially detected by MRI that were not initially seen on mammography or ultrasound. All patients with abnormalities found during the performance of second look ultrasound and biopsied were included in the study. All lesions were documented using the BIRADS lexicon for MRI and ultrasound. Of 100 included patients, 108 lesions were detected by MRI, found via second look ultrasound and biopsied between January 2008 and 2010. All of the included patients were followed-up for a variable period, from 2 to 5 years. Eighty-two upon 108 biopsied lesions (76%) were benign and 26/108 lesions (24%) were malignant. This study confirmed the switch from procubitus to decubitus essentially displaces the tumour in the antero-posterior direction. It showed that the risk factors were not reliable criteria for establishing an indication for second look ultrasound. This study also showed that circumscribed contours and a progressive enhancement curve (type I) for masses on MRI had the strongest negative predictive value of greater than 0.85. In ultrasound, the round or oval shape, circumscribed contours and the parallel orientation to the skin favoured benignity with a NPV of greater than 0.85. For masses, the study showed that the agreement in interpretation of the benign versus suspicious morphological criteria between the MRI and the ultrasound was very weak for the shape (Kappa=0.09) and weak for the contours (Kappa=0.23). Finally, the MRI overestimated the size of the targets compared to ultrasound (Student t-test, p=0.0001). The performance of second look ultrasound has to be performed after the detection of an abdnormality on MRI even for lesion classified BIRADS 3. The biopsy indications must be wide with insertion of a clip and a control MRI. Only this control allows to stop the investigation if the biopsied lesion is benign.

Perfusion studies in senology.

Microcirculation imaging in breast cancer involves studying tissue enhancement after contrast injection, which is used to calculate perfusion and permeability. The magnitude of enhancement reflects blood and interstitial volumes. This technique has benefitted from advances in MRI, which allow large volumes to be acquired with a good compromise between temporal and spatial resolution. Software has also advanced enabling microcirculation maps to be calculated and heterogeneity to be analyzed. If permeability is increased and interstitial volume is reduced, the microcirculation imaging suggests a suspicious aggressive lesion and can be used for early assessment of neoadjuvant therapies by demonstrating restoration of normal functional indices, which precede morphological changes.

Iron overload of hematological origin: validation of a screening procedure for cardiac overload by MRI in routine clinical practice.

PURPOSE: Screening for cardiac iron overload is generally done by magnetic resonance imaging (MRI) and demonstrated by a shortening of the myocardial T2* below 20 ms at 1.5 Tesla. This measurement was validated with a specific sequence and the CMRTools(®) calculation software (reference technique). The objective of this study was to validate the use of sequences and software programs that are available in routine clinical practice to screen for iron overload. MATERIAL AND METHODS: First, a phantom of 11 tubes with a T2* between 4 and 33 ms was tested at three sites that had MRI machines of different brands. Second, the myocardial T2* values of 75 patients were measured in routine clinical practice using two methods. The first method used the reference sequence specially installed in the machines associated with the CMRTool software. The second method used the standard acquisition sequences available in the machines followed by calculation on a computer spreadsheet. RESULTS: In the phantom, the mean of the differences in T2* between each machine was 0.6 ms. Thirteen patients had a lowered T2* value with the reference technique. Three cases were poorly classified using the routine technique and corresponded with false positives of low overload (T2* between 18 and 20 ms). CONCLUSION: Screening for myocardial iron overload can be done by MRI by using sequences and calculation software available in routine clinical practice during the same examination as the one for the evaluation of hepatic iron overload.

CT-guided biopsies in lung infections in patients with haematological malignancies.

CT-guided transparietal lung biopsy in imaging makes it possible to find the pathogenic agent in half of all fungal infections and most bacterial infections (sensitivity=55%, specificity=100%). Performance is decreased in consolidations (50% of infections) compared to masses. Complications, pneumothorax, alveolar bleeding and hemoptysis are generally benign and rarely (<5%) require specific treatment. On the other hand, the diagnostic performance increases significantly with the calibre of 18G co-axial systems compared to 20G. The risk is not related to the number of samples or platelet levels.

Body fat distribution in HIV-infected patients treated for 96 weeks with darunavir/ritonavir monotherapy versus darunavir/ritonavir plus nucleoside reverse transcriptase inhibitors: the MONOI-ANRS136 substudy.

OBJECTIVES: The aim of the study was to evaluate fat tissue distribution in HIV-infected patients with suppressed viraemia treated with darunavir/ritonavir (darunavir/r) monotherapy versus darunavir/r triple therapy. METHODS: This study was a substudy of the randomized, multicentre, open-label MONOI-ANRS 136 trial. Body fat distribution and metabolic parameters were measured at baseline, week 48 and week 96. RESULTS: In total, 156 patients of the 225 initially enrolled in the MONOI trial participated in this study, 75 in the darunavir/r monotherapy arm and 81 in the darunavir/r triple-therapy arm. The median limb fat increase from baseline was +0.34 kg [interquartile range (IQR) -0.040 to +1.140 kg; P < 0.001] at week 48 and +0.33 kg (IQR -0.14 to +1.26 kg; P = 0.001) at week 96 in the monotherapy arm, while there was no change (-0.02 kg; IQR -0.53 to +0.52 kg) at week 48 and then an increase of +0.23 kg (IQR -0.45 to +0.87 kg; P = 0.046) at week 96 in the triple-therapy arm. The two arms differed significantly at week 48 (P = 0.001) but not at week 96. The median increase in trunk fat was +0.73 kg (IQR -0.24 to +1.60 kg; P < 0.001) and 0.60 kg (IQR -0.41 to +1.49 kg; P = 0.03) at week 48 and +1.16 kg (IQR -0.17 to +2.75 kg; P < 0.001) and +0.90 kg (IQR -0.51 to +2.34 kg; P = 0.001) at week 96 in the monotherapy and triple-therapy arms, respectively, with no difference between arms. At week 96, the only biological change was a glucose level elevation in the monotherapy arm (median +4.0 mg/dL; IQR -4.0 to +7.0 mg/dL) compared with the triple-therapy arm (P = 0.012). CONCLUSIONS: Overall, body fat tissue increased in patients on darunavir/r monotherapy and triple therapy, with no difference between the arms over 96 weeks. The only difference found was a delayed increase in limb fat tissue in the triple-therapy arm compared with the monotherapy arm in the first year.

Image-guided needle biopsy for diagnosis and molecular biology in lymphomas.

Core needle biopsy is increasingly replacing excisional lymph node biopsy in the diagnosis and subclassification of malignant lymphomas, with obvious advantages in terms of morbidity and costs. This technique has radically altered the diagnostic strategy of enlarged lymph nodes at our institution, avoiding unnecessary nodal excisions. It represents a viable alternative as long as the number and size of cores for morphologic and molecular studies are not compromised. This quick and safe technique can be applied to the initial diagnostic evaluation of malignant lymphomas as well as the reassessment of previously diagnosed malignant lymphomas at time of progression or recurrence.

Breast inflammation: indications for MRI and PET-CT.

Breast MRI should not be used for differential diagnosis between inflammatory breast cancer and acute mastitis (AM) prior to treatment. When mastitis symptoms persist after 10 to 15 days of well-managed medical treatment, MRI may be performed in addition to an ultrasound examination, a mammogram and to taking histological samples, in order to eliminate inflammatory breast cancer (IBC). For staging, MRI would seem to be useful in looking for a contralateral lesion, PET-CT for finding information about remote metastases and in certain centres, for information about the initial extension to local/regional lymph nodes, which would guide the fields of irradiation (since patients can become lymph node negative after neoadjuvant chemotherapy). MRI and PET-CT seems to be useful for early detection of patients responding poorly to neoadjuvant chemotherapy so that the latter may be rapidly modified.

Visceral lesions occurring during follow-up of melanoma patients: a true place for other diagnosis than melanoma metastasis.

BACKGROUND: Diagnosis of melanoma metastasis is often based on a combination of clinical and radiological examinations in patients with a past history of melanoma. Chemotherapeutic treatment is often proposed without histological proof of the metastatic status. OBJECTIVE: The aim of this study was to investigate a cohort of melanoma patients with invasive diagnostic procedures (IDPs) for pathological confirmation of metastasis in case of suspicious visceral lesions. METHODS: A total of 109 melanoma patients with IDPs for suspicious visceral lesion(s) were included. Data about primary melanoma, IDPs characteristics, pathological result and therapeutic consequence were collected. Patients with AJCC Stage I-III melanoma at the time of the IDP were statistically analysed for various characteristics according to the final diagnosis yielded by the IDP. RESULTS: A total of 64 diagnostic surgical resections, 38 CT-guided core-needle biopsies, 15 ultrasound-guided core-needle biopsies, 6 surgical biopsies and 6 per-endoscopic biopsies were performed. Main target organs were the lungs (43.5%), breasts (8.5%) and liver (8%). IDPs were well tolerated and provided adequate samples for reliable diagnoses. Among the 105 IDPs in stage I-III patients, 56 melanoma metastases (53%), 25 benign lesions (24%) and 23 other cancers (22%) were found. One IDP was not informative. Multivariate analysis showed that nodular type of the primary melanoma, time-lag between primary melanoma and IDP over 12 months and the presence of suspicious lesions outside the organ biopsied were significantly associated with melanoma metastasis diagnosis. CONCLUSION: Suspected melanoma metastasis was ruled out for benign lesion or second cancer in nearly half of the stage I-III patients having undergone an IDP, therefore modifying the medical treatment.