Accuracy of ultrasound B-lines score and E/Ea ratio to estimate extravascular lung water and its variations in patients with acute respiratory distress syndrome.

Extravascular lung water (EVLW) could increase by permeability pulmonary oedema, cardiogenic oedema, or both. Transthoracic echocardiography examination of a patient allows quantifying B-lines, originating from water-thickened interlobular septa, and the E/Ea ratio, related to pulmonary capillary wedge pressure. The aim of our study was to assess the correlation and the trending ability between EVLW measured by transpulmonary thermodilution and the B-lines score or the E/Ea ratio in patients with ARDS. Twenty-six intensive care unit patients were prospectively included. B-lines score was obtained from four ultrasound zones (anterior and lateral chest on left and right hemithorax). E/Ea was measured from the apical four-chamber view. EVLW was compared with the B-lines score and the E/Ea ratio. A linear mixed effect model was used to take account the repeated measurements. A p value<0.05 was considered significant. A total of 73 measurements were collected. The correlation coefficient between EVLW and B-lines score was 0.66 (EVLW=0.71 B-lines+7.64, R2=0.44, p=0.001), versus 0.31 for E/Ea (p=0.06). The correlation between EVLW changes and B-lines variations was significant (R2=0.26, p<0.01), with a concordance rate of 74%. A B-lines score≥6 had a sensitivity of 82% and a specificity of 77% to predict EVLW>10 ml/kg, with an AUC equal to 0.86 (0.76-0.93). The gray zone approach identified a range of B-lines between four and seven for which EVLW>10 ml/kg could not be predicted reliably. The correlation between ultrasound B-lines and EVLW was significant, but the B-lines score was not able to track EVLW changes reliably.

[Breast surgeon role in the management of high-risk breast lesions]. / Quelle prise en charge chirurgicale pour "les lésions à haut risque" de cancer du sein?

Diagnostics of high-risk breast lesions have increased these last years with the augmentation of breast percutaneous biopsies. They are lesions that confer an enlarged risk of breast cancer, either because of an increased probability of finding cancer after open surgery, a possible evolution toward in situ or invasive cancer, or because of an increased probability of developing breast cancer over the long term. Much progress has been made these last years in their histological diagnostic, classification and pathogenesis. Nevertheless, no consensus exists to date on the management of these "high-risk" lesions. In particular, surgical indications and follow-up modalities remain controversial for each histological type. In this review, the principal factors that could impact surgical decision and long-term follow-up are discussed with areas of controversy highlighted.

[Recent data on lobular neoplasia of the breast: the pathologist's opinion]. / Données récentes sur les néoplasies lobulaires du sein: le point de vue du pathologiste.

Lobular neoplasia is the new WHO terminology that encompasses the so-called lobular carcinoma in situ and atypical lobular hyperplasia. Besides the classical forms, particular variants have been described, which are mammographically detectable with distinct histologic patterns and behaviour. These variants are characterized by pleomorphic cells, necrosis with calcifications and may be associated to an invasive lobular carcinoma. Their clinical issue looks more like a preinvasive lesion than a marker of increased risk. Thus, their identification on biopsy requires a surgical reexcision. Hybrid forms, sharing a mixed lobular and ductal morphology and phenotype, have also been mentionned. Despite a lack of prognostic evaluation, it seems logical to recommend a subsequent surgical investigation when they are observed. Classical forms are usually managed by simple follow-up, although this attitude does not make a consensus among pathologists. Lobular neoplasia are not all indolent lesions and belong to an heterogeneous group that percutaneous guided biopsies have emphasized. They should be managed in a pluridisciplinar way and correctly diagnosed on percutaneous biopsies as well as surgical specimens.

[Clinical Practice Guidelines 2004. Standards, Options and Recommendations for the management of patient with adenocarcinoma of the stomach: radiotherapy (therapeutic evaluation)]. / Recommandations pour la pratique clinique. Standards, Options et Recommandations 2004 pour la prise en charge des patients atteints d'adénocarcinomes de l'estomac, cancers du cardia, autres types histologiques exclus (évaluation des thérapeutiques).

CONTEXT: The "Standards, Options and Recommendations" (SOR) project, started in 1993, is a collaboration between the Federation of French Cancer Centers (FNCLCC), the 20 French regional cancer centers, and specialists from French Public Universities, General Hospitals and Private Clinics. The main objective is the development of clinical practice guidelines to improve the quality of health care and the outcome of cancer patients. OBJECTIVES: To elaborate clinical practice guidelines for patients with stomach adenocarcinoma. These recommendations cover the diagnosis, treatment and follow-up of these tumors. METHODS: The methodology is based on a literature review and critical appraisal by a multidisciplinary group of experts, with feedback from specialists in cancer care delivery. The Standards, Options and Recommendations are thus based on the best available evidence and expert agreement. RESULTS: This guidelines presents the synthesis of the data concerning the evaluation of the therapeutic ones. The main questions concern the type of gastrectomy to realize (Total Gastrectomy or gastrectomy subtotal), the extent of the lymphadenectomy (D2, D3 versus D1, D3, D2 versus D4) and the role of postoperative chemotherapy and adjuvant concomitant chemoradiotherapy.

[Management of non-palpable breast lesions with vacuum-assisted large core needle biopsies (Mammotome). Experience with 560 procedures at the Val d'Aurelle Center]. / Prise en charge des lésions mammaires infra-cliniques par macrobiopsies assistées par le vide (procédure Mammotome). Expérience du Centre Val d'Aurelle à propos d'une série de 560 procédures.

Percutaneous vacuum-assisted large core needle biopsy of breast microcalcifications is now commonly performed as the initial approach to nonpalpable breast lesions. It can obviate the need for surgery in women with benign lesions and often lead to a one-stage surgical procedure when malignant lesions are diagnosed. To illustrate this strategy, we describe our experience based on 560 procedures performed within a 36 Month-period. Sixty percent of the lesions were benign, mostly fibrocystic changes. Thirty percent of the specimens were malignant, almost exclusively intraductal carcinomas, sometimes associated with an invasive component. This component must be identified by the pathologist in order to avoid incomplete treatment and to plan lymph node excision. Finally, 10% of the specimens were boderline including lobular neoplasia, atypical ductal hyperplasia and columnar cell lesions with atypia. Surgical excision is recommended for atypical ductal hyperplasia, columnar cell lesions with atypia and lobular neoplasia with particular features, pleomorphic or comedo-like, to avoid missing more aggressive associated lesions. A strict procedure is required for the analysis of needle core biopsies and the subsequent surgical specimens, to accurately classify breast lesions provided by a mammographic screening program. This procedure should be based on a multidisciplinary approach and dialog.

Treatment of unresectable, locally advanced pancreatic adenocarcinoma with combined radiochemotherapy with 5-fluorouracil and cisplatin.

INTRODUCTION: Adenocarcinoma of the pancreas remains one of the most difficult malignancies to treat. Its incidence has steadily increased over the past four decades, and its prognosis is still dismal. AIM To assess tumor control and the palliative benefit of 5-fluorouracil (5-FU), cisplatin (CDDP), and radiotherapy in patients with advanced pancreatic cancer. METHODOLOGY: Systemic chemotherapy consisted of 5-FU (600 mg/m ), given as a 22-hour infusion on days 1 to 5, and CDDP (100 mg/m ), given as a 90-minute infusion on day 2. Treatment courses were repeated identically on day 21. Radiotherapy was delivered using megavolt irradiation of 25-MV photons with a two- or four-field isocentric technique. RESULTS: Twenty-seven patients were treated with this radiochemotherapy (RCT). Twenty-one patients (78%) completed initial treatment. The median dose of radiation therapy delivered was 42.5 Gy. At the time of evaluation (1 month after the end of the RCT), no grade 4 (WHO) toxicity was observed; 12 patients had improved or stable body weight; pain was improved for 20 patients, with 11 experiencing no pain; and analgesic consumption decreased for 18 patients, of whom 11 stopped intake. The clinical benefit response was 7/27 (26%). Median survival and time to progression were, respectively, 9 and 4.4 months. CONCLUSION: This RCT regimen had a good impact on clinical benefit in locally advanced pancreatic carcinoma, without severe side effects.