French AFU Cancer Committee Guidelines Update 2022-2024: Adrenal tumor - Assessment of an adrenal incidetaloma and oncological management

INTRODUCTION

The objective of this publication is to recall the initial work-up when faced with an adrenal incidentaloma and, if necessary, to establish the oncological management of an adrenal malignant tumor.

MATERIAL AND METHODS

The multidisciplinary working group updated French urological guidelines about oncological assessment of the adrenal incidentaloma, established by the CCAFU in 2020, based on an exhaustive literature review carried out on PubMed.

RESULTS

Although the majority of the adrenal masses are benign and non-functional, it is important to investigate them, as a percentage of these can cause serious endocrine diseases or be cancers. Malignant adrenal tumors are mainly represented by adrenocortical carcinomas (ACC), malignant pheochromocytomas (MPC) and adrenal metastases (AM). The malignancy assessment of an adrenal incident includes a complete history, a physical examination, a biochemical/hormonal assessment to look for subclinical hormonal secretion. Diagnostic hypotheses are sometimes available at this stage, but it is the morphological and functional imaging and the histological analysis, which will make it possible to close the malignancy assessment and make the oncological diagnosis.

CONCLUSIONS

ACC and MPC are mainly sporadic but a hereditary origin is always possible. ACC is suspected preoperatively but the diagnosis of certainty is histological. The diagnosis of MPC is more delicate and is based on clinic, biology and imagery. The diagnosis of certainty of AM requires a percutaneous biopsy. At the end, the files must be discussed within the COMETE - adrenal cancer network (Appendix 1).

French AFU Cancer Committee Guidelines - Update 2022-2024: penile cancer

OBJECTIVE

To update French oncology guidelines concerning penile cancer.

METHODS

Comprehensive Medline search between 2020 and 2022 upon diagnosis, treatment and follow-up of testicular germ cell cancer to update previous guidelines. Level of evidence was evaluated according to AGREE-II.

RESULTS

Epidermoid carcinoma is the most common penile cancer histology. Physical examination is mandatory to define local and inguinal nodal cancer stage. MRI with artificial erection can help to assess deep infiltration in cases of organsparing intention. Node negative patients (defined by palpation and imaging) will present micro nodal metastases in up to 25% of cases. Invasive lymph node assessment is thus advocated except for low risk patients. Sentinel node dynamic biopsy is the first line technique. Modified bilateral inguinal lymphadenectomy is an option with higher morbidity. 18-FDG-PET is recommended in patients with palpable nodes. Chest, abdominal and pelvis computerized tomography is an option. Fine needle aspiration (when positive) is an easy way to assess inguinal palpable node pathological involvement. Its results determine the type of lymphadenectomy to be performed (for diagnostic or curative purposes). Treatment is mostly surgical. Free margins status is essential, but it also has to be organ-sparing when possible. Brachytherapy and topic agents can cure in selected cases. Lymph node assessment should be synchronous to the removal of the tumour when possible. Limited inguinal lymph node involvement (pN1 stage) can be cured with the only lymphadenectomy. In case of larger lymph node stage, one should consider multidisciplinary treatment including chemotherapy and inclusion in a trial.

CONCLUSIONS

Penile cancer needs demanding surgery to be cured, surrounded by chemotherapy in node positive patients. Lymph nodes involvement is a major prognostic factor. Thus, inguinal node assessment cannot be neglected.

[French ccAFU guidelines - update 2020-2022: penile cancer]

OBJECTIVE

- To update French oncology guidelines concerning penile cancer.

METHODS

- Comprehensive Medline search between 2018 and 2020 upon diagnosis, treatment and follow-up of testicular germ cell cancer to update previous guidelines. Level of evidence was evaluated according to AGREE-II.

RESULTS

- Epidermoid carcinoma is the most common penile cancer histology. Physical examination is mandatory to define local and inguinal nodal cancer stage. MRI with artificial erection can help to assess deep infiltration in cases of organ-sparing intention. Node negative patients (defined by palpation and imaging) will present micro nodal metastases in up to 25% of cases. Invasive lymph node assessment is thus advocated except for low risk patients. Sentinel node dynamic biopsy is the first line technique. Modified bilateral inguinal lymphadenectomy is an option with higher morbidity. 18-FDG-PET is recommended in patients with palpable nodes. Chest, abdominal and pelvis computerized tomography is an option. Fine needle aspiration (when positive) is an easy way to assess inguinal palpable node pathological involvement. Its results determine the type of lymphadenectomy to be performed (for diagnostic or curative purposes). Treatment is mostly surgical. Free margins status is essential, but it also has to be organ-sparing when possible. Brachytherapy and topic agents can cure in selected cases. Lymph node assessment should be synchronous to the removal of the tumour when possible. Limited inguinal lymph node involvement (pN1 stage) can be cured with the only lymphadenectomy. In case of larger lymph node stage, one should consider multidisciplinary treatment including chemotherapy and inclusion in a trial.

CONCLUSIONS

- Penile cancer needs demanding surgery to be cured, surrounded by chemotherapy in node positive patients. Lymph nodes involvement is a major prognostic factor. Thus, inguinal node assessment cannot be neglected.

Improving the Diagnosis of the Frontal Variant of Alzheimer's Disease with the DAPHNE Scale

Background:

The frontal variant of Alzheimer’s disease (fAD) is poorly understood and poorly defined. The diagnosis remains challenging. The main differential diagnosis is the behavioral variant of frontotemporal degeneration (bvFTD). For fAD, there is some dissociation between the clinical frontal presentation and imaging and neuropathological studies, which do not always find a specific involvement of the frontal lobes. DAPHNE is a behavioral scale, which demonstrated excellent performance to distinguish between bvFTD and AD.

Objective:

The aim of the present study was to assess the reliability of this new tool to improve the clinical diagnosis of fAD.

Methods:

Twenty fAD patients and their caregivers were prospectively included and were compared with 36 bvFTD and 22 AD patients.

Results:

The three main behavioral disorders in the fAD patients were apathy, loss of empathy, and disinhibition. Three disorders were discriminant because they were less frequent and less severe in the fAD patients than in the bvFTD patients, namely hyperorality, neglect, and perseverations. This specific pattern of behavioral disorders was corroborated by SPECT or ¹⁸FDG PET-CT scan that showed that patients with fAD could have a medial frontal hypoperfusion, whereas in bvFTD patients the orbitofrontal cortex was the main involved region, with more diffuse hypoperfusion.

Conclusion:

We demonstrated that DAPHNE had good sensitivity and good specificity to discriminate between the three groups and in particular between fAD and bvFTD patients. DAPHNE is a quick tool that could help clinicians in memory clinics not only to differentiate bvFTD from typical AD but also from fAD.

[French ccAFU guidelines - update 2020-2022: malignancy assessment of an adrenal incidentaloma]

INTRODUCTION

- The objective of this publication is to recall the initial oncological management of adrenal incidentalomas.

MATERIAL & METHODS

- The multidisciplinary working group updated french urological guidelines established by the CCAFU in 2018, based on an exhaustive literature review carried out on PubMed.

RESULTS

- Although the majority of the adrenal masses are benign and non-functional, it is important to investigate them, as a percentage of these can cause serious endocrine diseases or be cancers. Malignant adrenal tumors are mainly represented by Adrenocortical Carcinomas (ACC), malignant pheochromocytomas (MPC) and adrenal metastases (AM). The malignancy assessment of an adrenal incident includes a complete history, a physical examination, a biochemical / hormonal assessment to look for subclinical hormonal secretion. Diagnostic hypotheses are sometimes available at this stage, but it is the morphological and functional imaging and the histological analysis which will make it possible to close the malignancy assessment and make the oncological diagnosis.

CONCLUSIONS

- AC and MPC are mainly sporadic but a hereditary origin is always possible. ACC is suspected preoperatively but the diagnosis of certainty is histological. The diagnosis of MPC is more delicate and is based on clinic, biology and imagery. The diagnosis of certainty of AM requires a percutaneous biopsy. At the end, the files must be discussed within the COMETE - adrenal cancer network (Appendix 1).

[French ccAFU guidelines - update 2020-2022: testicular germ cell tumors]

OBJECTIVE

- To update French guidelines concerning testicular germ cell cancer.

MATERIALS AND METHODS

- Comprehensive Medline search between 2018 and 2020 upon diagnosis, treatment and follow-up of testicular germ cell cancer and treatments toxicities. Level of evidence was evaluated.

RESULTS

- Testicular Germ cell tumor diagnosis is based on physical examination, biology tests (serum tumor markers AFP, hCGt, LDH) and radiological assessment (scrotal ultrasound and chest, abdomen and pelvis computerized tomography). Total inguinal orchiectomy is the first-line treatment allowing characterization of the histological type, local staging and identification of risk factors for micrometastases. In case of several therapeutic options, one must inform his patient balancing risks and benefits. Surveillance is usually chosen in stage I seminoma compliant patients as the evolution rate is low between 15 to 20%. Carboplatin AUC7 is an alternative option. Radiotherapy indication should be avoided. In stage I non seminomatous patients, either surveillance or risk-adapted strategy can be applied. Staging retroperitoneal lymphadenectomy has restricted indications. Metastatic germ cell tumors are usually treated by PEB chemotherapy according to IGCCCG prognostic classification. Lombo-aortic radiotherapy is still a standard treatment for stage IIA. Residual masses should be evaluated by biological and radiological assessment 3 to 4 weeks after the end of chemotherapy. Retroperitoneal lymphadenectomy is advocated for every non seminomatous residual mass more than one cm. 18FDG uptake should be evaluated for each seminoma residual mass more than 3 cm.

CONCLUSIONS

- A rigorous use of classifications is mandatory to define staging since initial diagnosis. Applying treatments based on these classifications leads to excellent survival rates (99% in CSI, 85% in CSII+).

Impact of Confinement on the Burden of Caregivers of Patients with the Behavioral Variant of Frontotemporal Dementia and Alzheimer Disease during the COVID-19 Crisis in France

Introduction

The clinical presentation of the behavioral variant of frontotemporal dementia (bvFTD) differs from that of Alzheimer disease (AD), with major impairments in behavioral functions in bvFTD and cognitive impairment in AD. Both behavioral disturbances in bvFTD and cognitive impairment in AD contribute to caregiver burden.

Objective

To investigate the impact of home confinement during the COVID-19 crisis on the burden of caregivers of bvFTD or AD patients.

Methods

During the COVID-19 lockdown in France, neurologists and neuropsychologists from the Memory Center of Nantes Hospital conducted teleconsultations for 38 AD patients and 38 bvFTD patients as well as for their caregivers. During these consultations, caregivers were invited to rate the change in their burden during home confinement. They were also invited to rate behavioral or emotional changes in the patients during, compared with before, the confinement.

Results

Twenty-two bvFTD caregivers and 14 AD caregivers experienced an increase in burden. For bvFTD caregivers, this increased burden occurred regardless of behavioral changes, while AD caregivers experienced an increased burden related to changes in patients' neuropsychiatric symptoms. Among the whole cohort, 2 factors were associated with increased caregiver burden: behavioral change and bvFTD.

Conclusion

The results demonstrate that during home confinement in the COVID-19 crisis, neuropsychiatric symptoms were the core factor that impacted caregiver burden in different ways depending on the disease.

When posterior cortical atrophy invests art: a case report

A 63-year-old woman was referred for visuospatial difficulties. The clinical and neuropsychological examination in association with imaging and biomarkers led to a diagnosis of posterior cortical atrophy (PCA). The patient, an amateur watercolor artist, continued to paint throughout her disease and her paintings illustrate in an original way the progression of her disorders. At an advanced stage, the evolution of neurovisual disorders is difficult to evaluate in patients. While studies have shown changes in artistic style in neurodegenerative diseases, none of them concerned PCA. Artistic production enables a different approach to trying to understand the progression of disorders.

[French ccAFU guidelines - Update 2018-2020: Testicular germ cell tumors]

OBJECTIVE

To update French guidelines concerning testicular germ cell cancer.

METHODS

Comprehensive Medline search between 2016 and 2018 upon diagnosis, treatment and follow-up of testicular germ cell cancer and treatments toxicities. Level of evidence was evaluated.

RESULTS

Testicular Germ cell tumor diagnosis is based on physical examination, biology tests (serum tumor markers AFP, hCGt, LDH) and radiological assessment (scrotal ultrasound and chest, abdomen and pelvis computerized tomography). Total inguinal orchiectomy is the first- line treatment allowing characterization of the histological type, local staging and identification of risk factors for micrometastases. In case of several therapeutic options, one must inform his patient balancing risks and benefits. Surveillance is usually chosen in stage I seminoma compliant patients as the evolution rate is low between 15 to 20 %. Carboplatin AUC7 is an alternative option. Radiotherapy indication should be avoided. In stage I non-seminomatous patients, either surveillance or risk-adapted strategy can be applied. Staging retroperitoneal lymphadenectomy has restricted indications. Metastatic germ cell tumors are usually treated by PEB chemotherapy according to IGCCCG prognostic classification. Lombo-aortic radiotherapy is still a standard treatment for stage IIA. Residual masses should be evaluated by biological and radiological assessment 3 to 4 weeks after the end of chemotherapy. Retroperitoneal lymphadenectomy is advocated for every non-seminomatous residual mass more than one cm. 18FDG uptake should be evaluated for each seminoma residual mass more than 3cm.

CONCLUSIONS

A rigorous use of classifications is mandatory to define staging since initial diagnosis. Applying treatments based on these classifications leads to excellent survival rates (99 % in CSI, 85 % in CSII+).

[French ccAFU guidelines - Update 2018-2020: Adrenal cancer]

OBJECTIVE

To update French oncology guidelines concerning adrenal cancer.

METHODS

Comprehensive Medline search between 2016 and 2018 upon diagnosis, treatment and follow-up of adrenal cancer to update 2013 guidelines. Level of evidence was evaluated according to AGREE-II.

RESULTS

Adrenal cancers are mainly represented by adrenocortical carcinomas (AC), malignant pheochromocytomas (MPC) and adrenal metastases (AM). Medical background of these tumors is either the exploration of hormonal or tumor symptoms, or an adrenal incidentaloma. Etiological explorations are based on hormonal biochemical assessment, morphological and functional imaging and histological analysis. AC and MPC are mostly sporadic but hereditary origin is still possible. The suspicion of AC is driven mainly by radiological signs of malignancy, signs of local invasion or distant metastasis, and type of hormonal secretion but the accurate diagnosis is histological. The diagnosis of MPC is clinical, biological and radiological. The diagnosis of MS involves a percutaneous biopsy. Medical files for primitive adrenal cancer should be discussed within the COMETE - Adrenal Cancer Network (Appendix 1). Oncological adjuvant treatments are specific for the histological type. In the AC, their indication depends on the risk of recurrence and is based on mitotane, external radiotherapy or chemotherapy. In the MPC, it is based on internal radiotherapy and chemotherapy. Metastatic forms treatment is exceptionally surgical. Debulking is uncommon. For metastatic unresectable AC, treatment is based on mitotane monotherapy or triple chemotherapy. For metastatic unresectable MPC, treatment is based on exclusive metabolic radiotherapy or triple chemotherapy. Recurrences are frequent and sometimes delayed, which justifies a close and long follow-up.

CONCLUSION

The curative treatment of Adrenal cancers is surgical provided. This treatment is rarely sufficient alone, the prognosis is then pejorative.

RETRACTED: Recommandations françaises du Comité de Cancérologie de l’AFU — Actualisation 2018—2020 : tumeur de la surrénale French ccAFU guidelines — Update 2018—2020: Adrenal cancer

This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). Cet article est retiré de la publication à la demande des auteurs car ils ont apporté des modifications significatives sur des points scientifiques après la publication de la première version des recommandations. Le nouvel article est disponible à cette adresse: doi:10.1016/j.purol.2019.01.011. C’est cette nouvelle version qui doit être utilisée pour citer l’article. This article has been retracted at the request of the authors, as it is not based on the definitive version of the text because some scientific data has been corrected since the first issue was published. The replacement has been published at the doi:10.1016/j.purol.2019.01.011. That newer version of the text should be used when citing the article.

RETRACTED: Recommandations françaises du Comité de Cancérologie de l’AFU — Actualisation 2018—2020 : tumeurs germinales du testicule French ccAFU guidelines — Update 2018—2020: Testicular germ cell tumors

This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). Cet article est retiré de la publication à la demande des auteurs car ils ont apporté des modifications significatives sur des points scientifiques après la publication de la première version des recommandations. Le nouvel article est disponible à cette adresse: doi:10.1016/j.purol.2019.01.009. C’est cette nouvelle version qui doit être utilisée pour citer l’article. This article has been retracted at the request of the authors, as it is not based on the definitive version of the text because some scientific data has been corrected since the first issue was published. The replacement has been published at the doi:10.1016/j.purol.2019.01.009. That newer version of the text should be used when citing the article.

RETRACTED: Recommandations françaises du Comité de Cancérologie de l’AFU — Actualisation 2018—2020 : sarcomes rétropéritonéaux French ccAFU guidelines — Update 2018—2020: Retroperitoneal sarcoma

This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). Cet article est retiré de la publication à la demande des auteurs car ils ont apporté des modifications significatives sur des points scientifiques après la publication de la première version des recommandations. Le nouvel article est disponible à cette adresse: doi:10.1016/j.purol.2019.01.010. C’est cette nouvelle version qui doit être utilisée pour citer l’article. This article has been retracted at the request of the authors, as it is not based on the definitive version of the text because some scientific data has been corrected since the first issue was published. The replacement has been published at the doi:10.1016/j.purol.2019.01.010. That newer version of the text should be used when citing the article.

RETRACTED: Recommandations françaises du Comité de Cancérologie de l’AFU — Actualisation 2018—2020: tumeurs du pénis French ccAFU guidelines — Update 2018—2020: Penile cancer

This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). Cet article est retiré de la publication à la demande des auteurs car ils ont apporté des modifications significatives sur des points scientifiques après la publication de la première version des recommandations. Le nouvel article est disponible à cette adresse: doi:10.1016/j.purol.2019.01.008. C’est cette nouvelle version qui doit être utilisée pour citer l’article. This article has been retracted at the request of the authors, as it is not based on the definitive version of the text because some scientific data has been corrected since the first issue was published. The replacement has been published at the doi:10.1016/j.purol.2019.01.008. That newer version of the text should be used when citing the article.

[Non-palpable testicular tumors in adults: A management based on imaging? Issue from the French Urologic Association Genital Cancer committee's edit]

BACKGROUND

Help in management of non-palpable testicular tumors. French Urologic Association Genital cancer committee's Edit.

OBJECTIVES

To review their characterization at imaging findings of non-palpable testicular tumors.

DOCUMENTARY SOURCES

Literature review (PubMed, Medline) of urological and radiological studies dealing with testicular tumors using keywords: non-palpable/incidental testicular tumors; color Doppler ultrasound; US elastography; magnetic resonance imaging; contrast enhanced sonography; partial surgery.

RESULTS

Color Doppler is the basic exam. The size, the presence of microlithts/microlithiasis/macrocalcifications, the vascular architecture are major semiological findings to suggest the benign or the malignant nature of the lesion. Other techniques like multiparametric MRI, contrast-enhanced sonography, sonographic elastography are still in evaluation. The frequency of benign tumors such as Leydig cell tumors lead to preservation management, through improved characterization, monitoring or tumorectomy.

LIMITS

Non-randomized study - a very few prospective studies.

CONCLUSION

The era of total orchiectomy for any uncertain testicular lesion is over. We try the challenge of characterization, and define management's algorithms based on the suspected nature of the tumors.

[CCAFU french national guidelines 2016-2018 on penile cancer]

INTRODUCTION

The aim of this work is to establish guidelines proposed by the external genital organ group of the CCAFU for the diagnosis, treatment and follow-up of penile cancer.

MATERIAL AND METHODS

The multidisciplinary working party studied 2013 guidelines exhaustively reviewed the literature, and evaluated references and their level of proof in order to attribute grades of recommandation.

RESULTS

The most common histological type is squamous cell carcinoma. Clinical examination of the penis is usually sufficient to access local extension. It can be completed by MRI to assess deeper extension. Physical examination of both groins must evaluate inguinal regional lymph nodes involvement. In the presence of palpable lymph nodes, abdomen and pelvis computed tomography and ¹⁸F-FDG PET-CT are recommended. Sentinel lymph node biopsy is recommended in the case of penile cancer with high risk of lymph node extension with no palpable lymph nodes. Treatment of the primary tumour is usually surgical. It must be as conservative as possible while ensuring negative surgical margins. Brachytherapy or local treatment can be proposed in some cases. Bilateral inguinal lymph node areas must be systematically treated. Inguinal lymphadenectomy alone has a curative role in patients with metastatic invasion of a single node (stage pN1). In the case of more extensive lymph node involvement, multimodal management combining chemotherapy, surgery, and possibly radiotherapy has to be considered.

CONCLUSIONS

The treatment of penile cancer is usually surgical possibly in combination with chemotherapy in the presence of lymph node extension. The main prognostic factor is lymph node involvement, requiring appropriate management at the time of diagnosis.x © 2016 Elsevier Masson SAS. All rights reserved.

Selection of an early biomarker for vascular normalization using dynamic contrast-enhanced ultrasonography to predict outcomes of metastatic patients treated with bevacizumab

BACKGROUND

Dynamic contrast-enhanced ultrasonography (DCE-US) has been used for evaluation of tumor response to antiangiogenic treatments. The objective of this study was to assess the link between DCE-US data obtained during the first week of treatment and subsequent tumor progression.

PATIENTS AND METHODS

Patients treated with antiangiogenic therapies were included in a multicentric prospective study from 2007 to 2010. DCE-US examinations were available at baseline and at day 7. For each examination, a 3 min perfusion curve was recorded just after injection of a contrast agent. Each perfusion curve was modeled with seven parameters. We analyzed the correlation between criteria measured up to day 7 on freedom from progression (FFP). The impact was assessed globally, according to tumor localization and to type of treatment.

RESULTS

The median follow-up was 20 months. The mean transit time (MTT) evaluated at day 7 was the only criterion significantly associated with FFP (P = 0.002). The cut-off point maximizing the difference between FFP curves was 12 s. Patients with at least a 12 s MTT had a better FFP. The results according to tumor type were significantly heterogeneous: the impact of MTT on FFP was more marked for breast cancer (P = 0.004) and for colon cancer (P = 0.025) than for other tumor types. Similarly, the differences in FFP according to MTT at day 7 were marked (P = 0.004) in patients receiving bevacizumab.

CONCLUSION

The MTT evaluated with DCE-US at day 7 is significantly correlated to FFP of patients treated with bevacizumab. This criterion might be linked to vascular normalization.

AFSSAPS NO

2007-A00399-44.

DAPHNE: A New Tool for the Assessment of the Behavioral Variant of Frontotemporal Dementia

BACKGROUND

The diagnosis of behavioral variant of frontotemporal dementia (bvFTD) relies primarily on clinical features and remains challenging. The specificity of the recently revised criteria can be disappointing, justifying development of new clinical tools.

OBJECTIVE

We produced a behavioral inventory named DAPHNE. This scale (adapted from Rascovsky's criteria) explores six domains: disinhibition, apathy, perseverations, hyperorality, personal neglect and loss of empathy. It is composed of ten items (five answer categories). The aim was (1) to assess the validity and reliability of DAPHNE and (2) to evaluate its contribution in differentiating patients.

METHODS

Two scores were computed: DAPHNE-6 (screening) from the six domains and DAPHNE-40 (diagnosis) from the ten items. Reliability and reproducibility were assessed. External validity was studied with the Frontal Behavioral Inventory (FBI) and the Frontotemporal Behavioral Scale (FBS). Finally, the diagnostic performance of DAPHNE was compared to revised criteria, FBI and FBS.

RESULTS

DAPHNE was administered to the caregivers of 89 patients, 36 with bvFTD, 22 with Alzheimer's disease, 15 with progressive supranuclear palsy and 16 with bipolar disorder. Reliability and reproducibility were excellent, as was external validity. DAPHNE-6 allowed bvFTD diagnosis (score ≥4) with a sensitivity of 92%, while DAPHNE-40 (score ≥15) had a specificity of 92%.

CONCLUSION

We demonstrate excellent psychometric features for DAPHNE. This quick tool could help for both diagnosing and screening bvFTD.

Use of the continuous glucose monitoring system to treat insulin autoimmune syndrome: quantification of glucose excursions and evaluation of treatment efficacy

BACKGROUND

Autoimmune hypoglycaemia, based on the presence of autoantibodies directed against endogenous insulin (insulin autoimmune syndrome or Hirata's disease), is a rare cause of hypoglycaemia. Treatment of the disease is not standardized and various therapeutic options have been proposed. We wondered whether using a continuous glucose-monitoring system could help quantify precisely glucose excursions and allow evaluation of treatment efficacy.

CASE REPORT

A 44-year-old Caucasian patient with insulin autoimmune syndrome was studied for 7 days using a continuous glucose monitoring system under various treatment regimens, i.e. diet modification, high-dose corticosteroids, alpha-glucosidase inhibitors, and plasmapheresis.

CONCLUSION

Continuous glucose monitoring system data confirmed that insulin autoimmune syndrome alternated between periods of prandial hyperglycaemia and interprandial hypoglycaemia. Alpha glucosidase inhibitors and plasmapheresis were more potent in limiting glucose excursions than corticosteroid or diet-only treatments. The continuous glucose monitoring system appears to be a useful tool in the management of insulin autoimmune syndrome.

Bilateral renal lymphangiomatosis: imaging and histopathologic findings

Renal lymphangiomatosis is an extremely rare disease characterized by developmental malformation of the lymphatic system surrounding the kidneys. We present the case of a 22-year-old pregnant female discovered because of worsening. Ultrasound, computed tomography, and magnetic resonance imaging studies were performed. An 18 × 11 × 10 cm voluminous cystic subcapsular lesion compressing the left kidney and subcapsular cysts of the right kidney were found. After the delivery, marsupialization was performed and the pathological analysis confirmed the diagnosis of lymphangiomatosis. A review of the literature is proposed.

[Metastatic melanoma in upper urinary tract: three cases and literature review]

Melanoma is a slowly growing malignancy, with potential distant metastasis at various sites. In this article, we reported three original cases of melanoma metastases in the upper urinary tract, and we achieved a literature review. Symptoms are inconstant and non-specific (pain or haematuria). Nephroureterectomy is performed in the majority of cases. Even if this metastatic location remains uncommon, it should be timely detected in order to allow an appropriate management and to improve the prognostic of melanoma.

REMOVAL: Pelvic MRI in a 17-year-old XY girl with 5-alpha reductase deficiency and a homozygous Gly115Asp mutation in SRD5A2

This article has been removed: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). This article has been removed at the request of the Editor-in-chief and the corresponding author for legal reasons regarding the patient consent.

[Renal failure: diagnostic work-up]

The purpose of this article is to review the diagnostic work-up of renal failure, acute or chronic. The role of the radiologist is to exclude the presence of a curable etiology such as urinary tract obstruction or vascular thrombosis. Renal ultrasound with Doppler imaging is the imaging modality of choice for this indication, and the use of a contrast agent is useful to evaluate renal perfusion. Non-contrast CT remains valuable for the diagnosis of some urinary tract pathologies. Finally, MRI is the most comprehensive imaging modality for the evaluation of the urinary tract, but performed as a second line modality mainly for practical reasons but also due to the non-negligible risk of nephrogenic systemic fibrosis secondary to the intravenous administration of gadolinium based contrast agent.

[Non-obstructive azoospermia: option of the testicular sperm extraction performed on the day of oocyte retrieval]

OBJECTIVE

Analyzing the results and validating the procedure of testicular sperm extraction (TESE) performed on the day of oocyte retrieval in non obstructive azoospermia (NOA) patients.

PATIENTS AND METHODS

Sixty TESE were performed on the day of oocyte retrieval (dOR), in 52 NOA men. Patients were sorted into three groups according to the results of the surgical procedure: 1: sperm recovery with possible sperm freezing (n=20); 2: sperm recovery without freezing (n=27); 3: "negative" biopsy (n=13). ICSI outcomes in the two groups with sperm recovery were compared to those of ICSI performed with frozen-thawed sperm obtained from TESE performed (n=13).

RESULTS

The rate of positive sperm retrieval was 78%. While the overall clinical pregnancy rate was 50%, no difference in the fertilization, implantation and clinical pregnancy rates was found in the two groups with positive sperm retrieval as compared to frozen-thawed sperm group. Twelve pregnancies were obtained in patients without further sperm cryopreservation.

CONCLUSION

After TESE in NOA men, cryopreserved sperm produced comparable results with freshly obtained sperm. However, TESE performed on dOR can offer the opportunity, in patients with rare sperm that might not survive freeze-thaw, to have a possible fresh embryo transfer. Couples should be counselled regarding the possibility of oocyte retrieval without sperm for ICSI.

Lésions hépatiques en cancérologie générale

In order to improve management of oncologic patients, a standardized 5-step approach should be considered: detection, characterization, locoregional and systemic staging, and post treatment follow up. The use of imaging techniques will be adapted to the clinical question at hand during multi-disciplinary review of cases. The role of the radiologist is to review the indications for each imaging modality and incorporate the results in the clinical context.

Le scanner multi détecteurs améliore la détection des perforations d’ulcères gastro duodénaux

OBJECTIVE

To determine whether multidetector computed tomography (MDCT) is helpful for early detection of gastroduodenal perforation.

MATERIAL AND METHODS

Fifteen consecutive gastroduodenal perforations for ulcer were recorded in the HIS of a single institution. Reports were analyzed and classified according to the following signs: Was a pneumoperitoneum detected? Was there mention of a perforation site, and how was it depicted (axial or reformatted slices, thin or thick slices)? What were the other described features, including peritoneal fluid, abdominal fat blurring, and bowel wall thickening?

RESULTS

All patients had a gastroduodenal perforation. MDCT identified pneumoperitoneum in 15 of 15 cases as compared with three of nine cases for plain films. The perforation site was seen in eight of 15: it was identified as a defect in the parietal wall (gastroduodenal). Six of eight cases were depicted in axial view. Two of them were only seen on MPR, coronal or sagittal view.

CONCLUSION

MDCT improves the detection rate of pneumoperitoneum and provides critical data for locating the perforation using direct and indirect signs. Multiplanar images seem to improve radiologists' confidence.

Hepatic venous pressure gradients measured by duplex ultrasound

AIMS

The hepatic venous pressure gradient is a major prognostic factor in portal hypertension but its measurement is complex and requires invasive angiography. This study investigated the relationship between the hepatic venous pressure gradient and a number of Doppler measurements, including the arterial acceleration index.

METHOD

We measured the hepatic venous pressure gradient in 50 fasting patients at hepatic venography. Immediately afterwards, a duplex sonographic examination of the liver was performed at which multiple measurements and indices of the venous and arterial hepatic vasculature were made.

RESULTS

Hepatic arterial acceleration was correlated directly with the hepatic venous pressure gradient (r=0.83, P<0.0001) and with the Child-Pugh score (r=0.63, P<0.0001). An acceleration index cut-off value of 1m.s(-2) provided a positive predictive value of 95%, a sensitivity of 65% and a specificity of 95% for detecting patients with severe portal hypertension (hepatic venous pressure gradient>12 mmHg). A correlation between the hepatic venous pressure gradient and the congestion index of the portal vein velocity (r=0.45,P=0.01) and portal vein velocity (r=0.40,P=0.044), was also noted.

CONCLUSION

Measuring the hepatic arterial acceleration index may help in the non-invasive evaluation of portal hypertension.

[Patterns physicians use to screen for gestational diabetes: descriptive analysis in a cohort of 701 women]

OBJECTIVE

To study the way physicians screen for gestational diabetes.

PATIENTS AND METHODS

Descriptive analysis of the pattern of screening used by physicians for 701 women who gave birth in a public or private maternity in the Rhône district in France.

RESULTS

Overall, a screening test was used in 17.7% of the women (95%CI 14.9-20.7). A 50 g glucose tolerance test was performed in 60% of the screening prescriptions and was positive in 37.3%. One-third of the screening tests were achieved after the 28th gestational week. About half of the women were at risk for gestational diabetes. Among them, 24.6% had had a screening test. Factors associated with prescription of a screening test were gestational diabetes or macrosomia in a previous pregnancy, diabetes in relatives, high body mass index, weight gain of more than 15 kg, African origin, and follow-up in a public maternity. The diagnosis of gestational diabetes was made in 9 women. The prevalence of gestational diabetes was 1.28% (95%CI 0.59%-2.42%).

CONCLUSION

Guidelines from the national colleges of obstetricians and endocrinologists for systematic screening for gestational diabetes are not properly applied. Questions concerning the implementation, results, and feasibility of these guidelines are raised.

[Natural history of focal nodular hyperplasia. A retrospective study of 44 cases]

AIM

To evaluate the natural course of focal nodular hyperplasia according to hormonal status.

METHODS

Forty-four patients were included in this retrospective study. Tumor size was assessed with ultrasound examination. We studied the influence of hormone status on the course of the disease.

RESULTS

All patients were women, the median age at diagnosis was 35 years and the median follow-up was 45 months. Ten patients were symptomatic at diagnosis, while none were symptomatic at the end of follow-up. The median size of the lesions was 56 mm. No complications occurred. The size of the tumor remained stable in 19 patients, increased in 12 and decreased in 13. Twenty-one of 37 patients stopped taking oral contraceptives at diagnosis: the lesion remained stable in 11 patients, increased in 3 and decreased in 7. Two patients didn't stop taking oral contraceptives: the lesion increased in one, decreased in the other. Six patients became pregnant and 6 patients went into menopause during follow-up: the lesion remained stable in 3 and 4 patients respectively.

CONCLUSION

Focal nodular hyperplasia is a benign lesion. Tumor size remained stable in most cases. It seems that the hormonal status has little or no influence on the course of the disease.

Randomized trial of tacrolimus plus mycophenolate mofetil or azathioprine versus cyclosporine oral solution (modified) plus mycophenolate mofetil after cadaveric kidney transplantation: results at 2 years

BACKGROUND

A previous report described the 1-year results of a prospective, randomized trial designed to investigate the optimal combination of immunosuppressants in kidney transplantation. Recipients of first cadaveric kidney allografts were treated with tacrolimus+mycophenolate mofetil (MMF), cyclosporine oral solution (modified) (CsA)+MMF, or tacrolimus+azathioprine (AZA). Results at 1 year revealed that optimal efficacy and safety were achieved with a regimen containing tacrolimus+MMF. The present report describes results at 2 years.

METHODS

Two hundred twenty-three recipients of first cadaveric kidney allografts were randomized to receive tacrolimus+MMF, CsA+MMF, or tacrolimus+AZA. All regimens contained corticosteroids, and antibody induction was used only in patients who experienced delayed graft function. Patients were followed up for 2 years.

RESULTS

The results at 2 years corroborate and extend the findings of the previous report. Patients randomized to either treatment arm containing tacrolimus experienced improved kidney function. New-onset insulin dependence remained in four, three, and four patients in the tacrolimus+MMF, CsA+MMF, and tacrolimus+AZA treatment arms, respectively. Furthermore, patients with delayed graft function/acute tubular necrosis who were treated with tacrolimus+MMF experienced a 23% increase in allograft survival compared with patients receiving CsA+MMF (P=0.06). Patients randomized to tacrolimus+MMF received significantly lower doses of MMF compared with those administered CsA+MMF.

CONCLUSIONS

All three immunosuppressive regi-mens provided excellent safety and efficacy. How-ever, the best results overall were achieved with tacrolimus+MMF. The combination may provide particular benefit to kidney allograft recipients who develop delayed graft function/acute tubular necrosis. Renal function at 2 years was better in the tacrolimus treatment groups compared with the CsA group.

[Evaluation of plain abdominal radiography prescriptions in a university hospital center]

OBJECTIVES

The aim of this study was to evaluate the prescription, impact and diagnostic utility of plain abdominal radiography in a University Hospital.

METHODS

Plain abdominal radiography series performed over 15 consecutive days were evaluated for quality and agreement with the patient's clinical status. Agreement between the final diagnosis and the radiographic findings were also compared. Contribution of plain abdominal radiography to final diagnosis was assessed on the basis of the conclusions on the hospital discharge report or from those drawn from a telephone survey. The same relationship was also assessed in terms of clinician status (medical student, resident physician, senior physician).

RESULTS

The series included 175 radiography series (11.6 per day). In 86% of the cases, the choice of views was adapted to the clinical context. In 14% it was not. The quality of the x-rays was found to be unsatisfactory in 17%, good in 63% and excellent in 20%. The radiography was considered to be contributive to the final diagnosis in 13% of the cases and non-contributive in 87%. Clinician status was not correlated with the degree of usefulness for final diagnosis. Finally, the prescription was in agreement with standard guidelines in 28% of the cases and not in agreement in 72%.

CONCLUSION

Plain abdominal radiographs are neither sensitive nor specific, frequently misleading, and costly per specific and correct diagnosis. Better physician awareness is required to limit the number of unnecessary examinations.

MR evaluation of factors predicting the development of rotator cuff tears

PURPOSE

The purpose of this work was to assess the incidence of various factors predicting impingement in the shoulder.

METHOD

MR examination was used to assess various anatomic parameters in 46 patients with clinical abnormalities of the shoulder and 40 asymptomatic volunteers. All patients had undergone surgery, showing no rotator cuff tear.

RESULTS

A few of the parameters evaluated were significantly different in the two groups: The acromion was more frequently curved or hook-shaped in patients than in volunteers. The acromiohumeral distances differed (4.87 mm in patients and 6.05 mm in volunteers); so did the coracohumeral distances (7.9 mm in patients and 8.9 mm in volunteers). The shape of the acromioclavicular joint and the anterior covering of the humerus, defined on the coronal view, also differed (1.07 mm in patients and 1.49 mm in volunteers). Only the shapes of the acromioclavicular joint and of the acromion were linked with age.

CONCLUSION

All these factors reflected a decrease in the acromiohumeral space, except for the anterior covering of the acromial arch, which could be due to anterior instability.

Primary malignant lymphoma of the urinary bladder: report of three cases and review of the literature

We report three cases of a primary malignant lymphoma of the urinary bladder. The radiological features revealed a sessile mass of the lateral wall for one case, a circumferential thickening in the second, and two separated masses of the bladder wall in the last case. Primary malignant lymphoma of the urinary bladder is extremely rare. From a review of the literature, the clinical and radiological findings are discussed. In this paper we report the first case of urinary bladder lymphoma presented on CTas multiple masses.