Multimodal management of primary adenocarcinoma of the female urethra: About four cases.

PURPOSE: To retrospectively analyse female patients treated for urethral adenocarcinoma, modalities of treatment and long-term outcomes. PATIENTS: Four cases of primary female urethral adenocarcinoma were treated in the departments of urology and radiation-oncology at Georges-Pompidou and Necker hospitals (France) over a 7-year period. RESULTS: All of them underwent surgery, with three presenting stage pT3-pT4 and one a positive cytology on inguinal node. Three patients received adjuvant cisplatin-based chemoradiotherapy up to 60Gy, and one preoperative chemoradiotherapy at 45Gy. Two recurrences were observed: one local relapse occurred at 9months from the diagnosis and was treated by anterior pelvic exenteration followed by chemoradiotherapy, with no recurrence. One tumour relapsed both at the local level and on distant metastatic sites at 9months from the diagnosis, and died 21months after this progression. Median survival and progression-free survival are respectively 4.2years and 13months. Three patients are alive at 7, 4.5 and 3years from diagnosis. CONCLUSION: Female urethral adenocarcinoma is a very rare entity and often present in locally advanced stages. Initial extensive surgery with pelvic exenteration should be considered, followed by chemoradiotherapy according to the surgical margins and lymph nodes involvement.

Double-echo gradient chemical shift MR imaging fails to differentiate minimal fat renal angiomyolipomas from other homogeneous solid renal tumors.

OBJECTIVES: The purpose of this retrospective study was to evaluate the diagnostic performance of double-echo gradient chemical shift (GRE) magnetic resonance (MR) imaging for the differentiation of angiomyolipomas with minimal fat (mfAML) from other homogeneous solid renal tumors. METHODS: Between 2005 and 2010 in two institutions, all histologically proven homogenous solid renal tumors imaged with computed tomography and MR imaging, including GRE sequences, have been retrospectively selected. A total of 118 patients (mean age: 61 years; range: 20-87) with 119 tumors were included. Two readers measured independently the signal intensity (SI) on GRE images and calculated SI index (SII) and tumor-to-spleen ratio (TSR) on in-phase and opposed-phase images. Intra- and interreader agreement was obtained. Cut-off values were derived from the receiver operating characteristic (ROC) curve analysis. RESULTS: Twelve mfAMLs in 11 patients were identified (mean size: 2.8cm; range: 1.2-3.5), and 107 non-AML tumors (3.2cm; 1-7.8) in 107 patients. The intraobserver reproducibility of SII and TSR was excellent with an intraclass correlation coefficient equal to 0.99 [0.98-0.99]. The coefficient of correlation between the readers was 0.99. The mean values of TSR for mfAMLs and non-mfAMLs were -7.0±22.8 versus -8.2±21.2 for reader 1 and -6.7±22.8 versus -8.4±20.9 for reader 2 respectively. No significant difference was noticed between the two groups for SII (p=0.98) and TSR (p=0.86). Only 1 out of 12 mfAMLs and 11 of 107 non-AML tumors presented with a TSR inferior to -30% (p=0.83). CONCLUSION: In a routine practice, GRE sequences cannot be a confident tool to differentiate renal mfAMLs from other homogeneous solid renal tumors.

Renal papillary carcinoma: CT and MRI features.

PURPOSE: To describe the CT and MRI appearances of papillary renal cell carcinoma. MATERIALS AND METHODS: Retrospective study of 102 papillary carcinomas in 79 patients, 81 tumors examined by CT and 56 by MRI. Tumor size, homogeneity and contrast enhancement were recorded. RESULTS: The most common presentation of papillary renal cell carcinoma was a small homogeneous hypovascular tumor both on CT and MRI. Eighty-nine percent of lesions were hypointense on T2 weighted images compared to the renal parenchyma. Seventeen percent of the lesions did not significantly enhance with contrast on CT. All of the lesions examined on MRI had a significant enhancement percentage. Calcifications were rare and only seen in 7% of cases (CT). The second most common presentation was a bulky necrotic tumor. In addition, atypical types of disease were found which were difficult to diagnose, including infiltrating tumors and tumors with a fatty component. CONCLUSION: A homogeneous hypovascular renal tumor which is hypointense on T2 weighted images should suggest a diagnosis of papillary carcinoma. Some papillary carcinomas do not enhance significantly on CT. MRI is then required to diagnose the renal tumor.

Ultrasound elastography of the prostate: state of the art.

Prostate cancer is the cancer exhibiting the highest incidence rate and it appears as the second cause of cancer death in men, after lung cancer. Prostate cancer is difficult to detect, and the treatment efficacy remains limited despite the increase use of biological tests (prostate-specific antigen [PSA] dosage), the development of new imaging modalities, and the use of invasive procedures such as biopsy. Ultrasound elastography is a novel imaging technique capable of mapping tissue stiffness of the prostate. It is known that prostatic cancer tissue is often harder than healthy tissue (information used by digital rectal examination [DRE]). Two elastography techniques have been developed based on different principles: first, quasi-static (or strain) technique, and second, shear wave technique. The tissue stiffness information provided by US elastography should improve the detection of prostate cancer and provide guidance for biopsy. Prostate elastography provides high sensitivity for detecting prostate cancer and shows high negative predictive values, ensuring that few cancers will be missed. US elastography should become an additional method of imaging the prostate, complementing the conventional transrectal ultrasound and MRI. This technique requires significant training (especially for quasi-static elastography) to become familiar with acquisition process, acquisition technique, characteristics and limitations, and to achieve correct diagnoses.

[Imaging of male infertility: techniques and results]. / Imagerie de l'hypofertilité masculine : technique et résultats.

Assessment of male infertility includes clinical examination, laboratory tests (semen analysis, hormones dosage) and sonographic examination of the urogenital tract. Male infertility is due to testicular abnormalities (secretory type) or obstructive disorder (excretory type). Imaging should provide accurate definition of anatomical causes of infertility in order to deliver appropriate treatment. Testicular Doppler ultrasound with transrectal ultrasound is the gold standard imaging technique to explore male infertility. MRI, because of its high resolution, provides a multiplanar study especially in congenital and inflammatory abnormalities of the urogenital tract. This pictorial review illustrates the most frequent causes of male infertility.

[Lymphadenectomy and prostate cancer: a statement of the committee of cancerology of the French Association of Urology]. / Le curage ganglionnaire dans le cancer de la prostate: une mise au point du comité de cancérologie de l'association française d'urologie.

Lymph node invasion is the first step of metastatic evolution of prostate cancer. In this case, today, no local treatment should be proposed. Detection of lymph node invasion is performed by CT-scan and RMI, which show hypertrophied nodes. No difference in term of sensibility and specificity is observed between CT-scan and RMI. Invaded nodes are defined by modifications of size, form, and aspect of the architecture of nodes. Sentinel node belongs to expert centers. Surgical lymphadenectomy remains the best way to evaluate lymph node status. Limited to ilio-obturator land, it underestimates the risk of lymph node invasion: Extended lymph node excision defined by the association of bilateral ilio-obturator, internal iliaca and external iliaca lymphadenectomy should be systematically proposed to intermediate and high risk prostate cancer. A "well done" lymphadenectomy is represented by more than 10 nodes removed. Lymph node invasion represents bad prognosis. However, therapeutic value and influence of prognosis of lymphadenectomy in prostate cancer is still not established. Therefore, one or two invade lymph nodes represented a population of patients with better prognosis, specially if no capsular effraction is observed. After radical prostatectomy, in case of lymph node invasion, immediate hormonotherapy is the standard; however, this treatment is discussed in case of low number of invaded nodes (one or two) and if postoperative PSA is equal to zero. In this case, radiotherapy is still in evaluation and chemotherapy has no indication.

How to characterise a solid renal mass: a new classification proposal for a simplified approach.

The reference method for characterising a solid renal mass is computed tomography. MRI and ultrasound can provide useful diagnostic information for characterising masses the cystic or solid nature of which it is not possible to determine from data from the CT scan. For characterising a solid mass, only MRI can replace the CT scan in most cases. Once a mass has been shown to be solid and vascularised and not occurring in a context suggesting an inflammatory pseudotumour, it can be put, using CT, into one of the four categories of the classification that we propose: pseudotumoral dysmorphisms (type 1); typical high-fat angiomyolipomas (type 2); suspect indeterminate tumours (type 3); typically malignant tumours (type 4).

Endorectal 3D T2-weighted 1mm-slice thickness MRI for prostate cancer staging at 1.5Tesla: should we reconsider the indirects signs of extracapsular extension according to the D'Amico tumor risk criteria?

PURPOSE: To evaluate the accuracy of a 3D-endorectal 1mm-thick slices MRI acquisition for local staging of low, intermediate and high D'Amico risk prostate cancer (PCa). MATERIALS AND METHODS: 178 consecutive patients underwent a multiparametric MRI protocol prior to radical prostatectomy (RP). T2W images were acquired with the 3D sampling perfection with application optimized contrasts using different flip angle evolutions (SPACE) sequence (5mn acquisition time). Direct and indirect MRI signs of extracapsular extension (ECE) were evaluated to predict the pT stage. The likelihood of SVI (seminal vesicle invasion) was also assessed. RESULTS: Histology showed ECE and SVI in 38 (21%) and 12 (7%) cases, respectively. MRI sensitivity and specificity to detect ECE were 55 and 96% if direct signs of ECE were used and 84 and 89% (p<0.05), if both direct and indirect signs were combined. D'Amico criteria did not influence MRI performance. Sensitivity and specificity for SVI detection were 83% and 99%. CONCLUSIONS: 3D data sets acquired with the SPACE sequence provides a high accuracy for local staging of prostate cancer. The use of indirect signs of ECE may be recommended in low D'Amico risk tumors to optimise patient selection for active surveillance or focal therapy.

[High-risk prostate cancer. Review by the Oncology Committee of the French Urology Association]. / Cancer de la prostate à haut risque de progression. Article de revue du comité de cancérologie de l'association française d'urologie.

INTRODUCTION: Localized prostate tumors have various clinical, biological and histopathological characteristics that lead to different progression profiles. High-risk prostate cancer has been classically defined by clinical examination, PSA levels and histopathological data. High-risk prostate cancer has usually a worse outcome, but classic stratification predictive of outcome for prostate cancer is a matter of debate concerning its accuracy. METHODS: A systematic review of the literature on high-risk prostate cancer over the 15 last years was carried out on Medline database. The literature selection was based on evidence and practical considerations. RESULTS: A great deal of scientific work have been deployed to prove that high-risk prostate cancer should be approached by teamwork including radio-hormone therapy, systemic treatment with long term use of LH-RH and a radical prostatectomy with adequate lymph node dissection. Selection of patients is essential to define individualized therapeutic strategy and timing for every modality should come as a consensus of medical supported evidence. CONCLUSION: Accurate patient selection and multimodal treatment offer the best therapeutic option in high-risk prostate cancer.

Multiparametric MRI is helpful to predict tumor focality, stage, and size in patients diagnosed with unilateral low-risk prostate cancer.

To study the staging accuracy of multiparametric magnetic resonance imaging (MRI) in patients showing unilateral low-risk cancer on prostate biopsy. A total of 58 consecutive patients with low-risk cancer (D'Amico classification) and unilateral cancer involvement on prostate biopsies were included prospectively. All patients underwent multiparametric endorectal MRI before radical prostatectomy, including T2-weighted (T2W), diffusion-weighted (DW) and dynamic contrast enhanced (DCE) sequences. Each gland was divided in eight octants. Tumor foci >0.2 cm(3) identified on pathological analysis were matched with MRI findings. Pathological examination showed tumor foci >0.2 cm(3) in 50/58 glands (86%), and bilateral tumor (pathological stagepT2c) in 20/58 (34%). For tumor detection in the peripheral zone (PZ), T2W+DWI+DCE performed significantly better than T2W+DWI and T2W alone (P<0.001). In the transition zone (TZ), only T2W+DWI performed better than T2W alone (P=0.02). With optimal MR combinations, tumor size was correctly estimated in 77% of tumor foci involving more than one octant. Bilateral tumors were detected in 80% (16/20) of cases. In patients with unilateral low-risk prostate cancer on biopsy, multiparametric MRI can help to predict bilateral involvement. Multiparametric MRI may therefore have a prognostic value and help to determine optimal treatment in such patients.

[Critic analysis of a comparative meta-analysis on the morbidity, functional and carcinologic results after radical prostatectomy according to surgical approach. Work of cancerology committee of the French urological association]. / Analyse critique d'une méta-analyse comparative sur la morbidité, les résultats fonctionnels et carcinologiques de la prostatectomie totale en fonction de la voie d'abord utilisée. Travail du comité de cancérologie de l'AFU.

Surgical approach for radical prostatectomy is even today a subject of debate in the urologic community. Many comparative studies between retropubic and laparoscopic approach (robotic assisted or not) were reported since 10 years without being able to decide between the supporters of retropubic or laparoscopic approach. The committee of cancer research of the French urological association took hold this question after a recent meta-analysis publication on this subject. Although imperfect, this meta-analysis exists and permits to conclude partially on the advantages and the inconveniences supposed for each surgical approach. Regarding morbidity after radical prostatectomy, the only significant difference reported concerns the hemorrhagic risk in favour of the laparoscopic approach. Regarding oncologic results, the only exploitable data concern positive surgical margins rate, which is identical whatever surgical approach. Concerning the functional results, no difference was reported in the literature between different surgical approaches.

[Impingement and kinesiology]. / Cinésiologie et conflits.

During physical activity, especially in sport, repeated and/or exaggerated movements may lead to different impingements. Rupture, luxation, and tendon insertion injuries are seen after mobilization in the acute phase, but the goal of this paper is to analyze chronic impingements. It is possible to see the consequences of these impingements in all the musculoskeletal structures but, in relation to movement, three groups can be described. In the first, there is chronic compression and percussion between two structures; in the second there is entrapment and friction, and in the third, there is distraction. These impingements are frequent and are seen in all people, but particular movements during sport can increase their frequency.

[Renal oncocytoma: CT diagnostic criteria revisited]. / Adénome oncocytaire du rein: redéfinition des critères diagnostiques en tomodensitométrie.

PURPOSE: To redefine and evaluate the computed tomographic criteria for the diagnosis of renal oncocytoma (RO) for which renal sparing surgery should be preferred. MATERIAL AND METHOD: Retrospective study of 57 patients with 69 RO. Macroscopic and histological correlation was obtained in all cases. A double blinded comparative study was made of 60 renal tumors (containing adenocarcinomas and oncocytomas) larger than 3 cm in diameter in order to evaluate the redefined CT diagnostic criteria. RESULTS: Among RO larger than 3 cm in diameter, 55% presented a sharply defined low attenuation scar on post-contrast scans at the tubular nephrographic phase, central or eccentric, with homogeneous attenuation throughout the remainder of the hypervascular tumor which was classified in 3 different groups. The use of our CT diagnostic criteria gave a statistically significant (p < 0.05) Kappa index of inter-observer concordance of 0.71 and a specificity of 96% for the diagnosis of RO. CONCLUSION: Our redefined computed tomographic criteria for the diagnosis of renal oncocytoma, eventually associated with renal biopsy, should increase the indications for renal sparing surgery for RO larger than 3 cm in diameter.

[Ultrasound of acute disorders of the shoulder]. / L'echographie dans les atteintes aiguës de l'epaule.

Acute pain of the shoulder, with or without associated injury shows specific features that enable differentiation from chronic lesions. Osteo-articular injuries, tendinous lesions, bursitis and moving calcification may produce acute pain. Examination of the acromio-clavicular joint is also essential as acromial lesions are often overlooked in emergency radiology. Along with X-ray radiography, sonography, if adequately performed, is able to determine the etiology of acute pain and to establish lesion staging.

[Diagnostic imaging of peripheral renal vascular disorders]. / Imagerie diagnostique de la pathologie vasculaire rénale périphérique.

Peripheral vascular disorders of the kidney involve the intrarenal branches of the renal vascular tree. It include occlusive (infarction and cortical necrosis) and non-occlusive vascular lesions (acquired arteriovenous fistulas, arteriovenous malformation, false aneurysms and microaneurysms). Initial diagnosis relies on color Doppler US and CT angiography. Angiography plays a therapeutic role. MR imaging provides useful diagnostic information on perfusion disorders especially in patients with renal insufficiency.