B. Gallix

MR Volumetric Measurement of Low Rectal Cancer Helps Predict Tumor Response and Outcome after Combined Chemotherapy and Radiation Therapy

PURPOSE To retrospectively determine whether magnetic resonance (MR) volumetry of rectal cancer is a reproducible method for predicting disease-free survival (DFS) in patients with locally advanced low or midrectal tumors who undergo combined chemotherapy and radiation therapy (CRT) before total mesorectal excision. MATERIALS AND METHODS The institutional review board does not require approval for the use of patient data obtained for an observational retrospective study. Fifty-eight patients were included in the study; 42 patients had low-lying tumors. Two radiologists independently measured tumor volumes before and after CRT with use of semiautomated software. The radiologists were blinded to the clinical information for each patient. The tumor volume reduction ratio, circumferential resection margin, T stage, and occurrence of downstaging were compared with the histopathologic response and DFS. The threshold of tumor volume reduction for predicting DFS was assessed with receiver operating characteristic curve analysis. DFS was estimated with the Kaplan-Meier method and compared between groups with the log-rank test. RESULTS The interobserver correlation coefficient between the two radiologists was 0.87 (95% confidence interval [CI]: 0.76, 0.93) for pre-CRT volumetry and 0.81 (95% CI: 0.74, 0.90) for post-CRT volumetry. A tumor volume reduction of at least 70% was significantly associated with good histologic regression (tumor regression grade [TRG], 3 or 4) (P <.0001) compared with a volume reduction rate of less than 70%. DFS was studied in 51 patients. The mean follow-up of survivors at the time of analysis was 52 months ± 20 (standard deviation). Patients with a volume reduction ratio of at least 70% had a higher DFS (P <.0001). Tumor volume reduction was an independent prognostic parameter in multivariate analysis for DFS (P = .003; 95% CI: 0.01, 0.4). CONCLUSION The results demonstrate that volumetric measurements are reliable markers of rectal cancer prognosis, enabling the prediction of DFS and TRG. The cutoff of 70% is an easy parameter to use as a surrogate for clinical response to predict both TRG and outcome.

Lung morphology predicts response to recruitment maneuver in patients with acute respiratory distress syndrome.

Objectives:The impact of recruitment maneuvers on gas exchange, hemodynamics, alveolar recruitment, and hyperinflation is highly variable among patients with acute respiratory distress syndrome. The objective was to determine whether differences in lung morphology, defined as differences in the pulmonary distribution of aeration loss, predict the response to recruitment maneuvers. Design:Prospective study. Setting:A 16-bed medical–surgical intensive care unit in a university hospital. Measurements and Main Results:Nineteen consecutive patients with early acute lung injury/acute respiratory distress syndrome were studied. Computed tomography scans, respiratory mechanics, hemodynamics, and gas exchange were obtained at zero end-expiratory pressure during an open-lung ventilation (controlled mode, tidal volume 6 mL/kg of ideal body weight, positive end-expiratory pressure set 2 cm H2O above the lower inflection point of the inspiratory pressure volume curve at zero end-expiratory pressure) during a recruitment maneuver (continuous positive airway pressure of 40 cm H2O for 40 secs), and, finally, 5 mins after the recruitment maneuver during open-lung ventilation. Nine patients presented focal and 10 presented nonfocal lung morphology at zero end-expiratory pressure. Recruitment maneuver-induced recruited volume after 5 mins of open-lung ventilation was 48 ± 66 mL and 417 ± 293 mL in patients with focal and nonfocal lung morphology, respectively (p = .0009). Recruitment maneuver-induced alveolar hyperinflation represented 23% ± 14% and 8% ± 9% of total lung volume in patients with focal and nonfocal morphology, respectively (p = .007). In patients with focal lung morphology, hyperinflated lung volume was significantly greater during and 5 mins after (316 ± 155 mL) than immediately before recruitment maneuvers (150 ± 175 mL; p = .0407. Conclusion:Lung morphology at zero end-expiratory pressure predicts the response to recruitment maneuvers. Patients with focal lung morphology are at risk for significant hyperinflation during the recruitment maneuvers, and lung recruitment is rather limited.

Liver transplantation and spontaneous neovascularization after arterial thrombosis: ''the neovascularized liver''

The only arterial pathway available after liver transplantation is the hepatic artery. Therefore, hepatic artery thrombosis can result in graft loss necessitating re‐transplantation. Herein, we present evidence of neovascularization at long‐term follow‐up in a series of transplant patients with hepatic artery thrombosis. We termed this phenomenon “neovascularized liver”. Hepatic artery thrombosis was noted in 30/407 cases (7.37%), and occurred early in 13 patients (43.3%) and late (>30 days) in 17 (56.7%) patients. At the time of this study, 11 (36.7%) patients had a neovascularized liver. Those patients with neovascularized liver and normal liver function were closely followed. Of these patients, 10 (91%) showed evidence of neovascularized liver by imaging, and an echo‐Doppler arterial signal was recorded in all patients. The mean interval between the diagnosis of hepatic artery thrombosis and neovascularized liver was 4.1 months (range of 3–5.5 months). Liver histology showed an arterial structure in 4 (36.4%) patients. Four factors were associated with development of neovascularized liver: late hepatic artery thrombosis, early hepatic artery stenosis, site of thrombosis, and Roux‐en‐Y anastomosis. The overall survival rate at 54 months was 90.9%. In conclusion, a late hepatic artery thrombosis may be quite uneventful and should not automatically lead to re‐transplantation.

R2: The Absence of Adrenal Gland Enlargement during Septic Shock Predicts Mortality: A Computed Tomography Study of 239 Patients

Background:Assessment and management of septic shock associated adrenal function remain controversial. The aim of this study was to explore the prognostic value of adrenal gland volume in adults with septic shock. Methods:A short cosyntropin test and determination of adrenal volume by computed tomography were performed within 48 h of shock in patients with septic shock (n = 184) and in 2 control groups: 40 ambulatory patients and 15 nonseptic critically ill patients. The primary endpoint was intensive care unit mortality. Results:At intensive care unit discharge, 59 patients with septic shock died. Adrenal volume was 12.5 cm3 [95% CI, 11.3–13.3] and 8 cm3 [95% CI, 6.8–10.1] in the nonseptic group (P < 0.05 with both septic cohorts) and 7.2 cm3 [95%CI, 6.3–8.5] in the ambulatory patient group (P < 0.05 in patients with septic shock). In patients with septic shock, adrenal volume less than 10 cm3 was associated with higher 28-day mortality rates with an area under the receiver operating curve of 0.84 [95% CI, 0.78–0.89]. Adrenal volume above 10 cm3 was an independent predictor of intensive care unit survival (hazard ratio = 0.014; 95% CI [0.004–0.335]). Conclusion:A total adrenal gland volume less than 10 cm3 during septic shock was associated in univariate and multivariate analysis with mortality at day 28 in patients with septic shock. Whether adrenal gland volume can be a surrogate of adrenal gland function and used to guide hydrocortisone therapy in septic shock patients needs to be further investigated.

Hepatic artery complications following liver transplantation. Does preoperative chemoembolization impact the postoperative course

Transarterial chemoembolization (TACE) in patients with hepatocellular carcinoma (HCC) may cause damage to the hepatic artery (HA) and impact the postoperative course of the liver transplantation (LT). We aim to describe the relationship between preoperative TACE and the occurrence of histological and radiological hepatic artery complications (HAC).

Neoadjuvant chemotherapy evaluation by MRI volumetry in rectal cancer followed by chemoradiation and total mesorectal excision: Initial experience.

To evaluate rectal cancer volumetry in predicting initial neoadjuvant chemotherapy response.

Une angiocholite : comment la reconnaître ? Quelles conduites à tenir ?

Resume L’angiocholite est l’infection de la bile ; elle est liee a une stase biliaire, consequence d’un obstacle sur le choledoque. Dans 85 % de cas, l’obstruction biliaire est due a la presence d’un calcul de la voie biliaire principale. Le diagnostic d’angiocholite doit etre imperativement fait de facon precise et rapide afin de pouvoir mettre en place le traitement adapte en urgence. L’echographie reste l’examen de premiere intention chez les patients suspects d’angiocholite d’origine lithiasique. Malheureusement, la dilatation des voies biliaires n’est pas toujours presente a la phase aigue et les performances de l’echographie pour detecter les calculs de la voie biliaire principale, sont mediocres. La tomodensitometrie sans injection, avec acquisitions en coupes fines, est plus sensible que l’echographie. Elle reste cependant moins performante que la cholangio-IRM, qui avec l’echo-endoscopie, est la technique la plus sensible pour detecter des calculs du bas choledoque. Chez les patients qui n’ont pas ete cholecystectomises, les donnees cliniques, biologiques, et echographiques permettent de suspecter la presence d’un calcul de la voie biliaire principale, meme s’il n’est pas directement individualisable en echographie. Ces donnees probabilistes sont suffisantes pour indiquer la realisation d’une cholecystectomie, a condition que tous les patients puissent beneficier en per-operatoire d’une cholangiographie directe.

Traitement de l’obésité morbide par anneau gastrique ajustable : un suivi clinique et radiologique

Resume Objectifs Le but de cette mise au point est de definir et illustrer le role de la radiologie apres la mise en place d’un anneau gastrique ajustable dans le traitement de l’obesite morbide. Patients et methode Depuis 1996, 1 000 patients obeses morbides ont ete traites par cette technique dans notre institution. Notre experience est basee sur une etude retrospective portant sur 663 patients obeses morbides avec 2 types d’anneaux, (de Septembre 1996 a Septembre 2002), est rapportee : 114 avec un anneau de type Lapband (LB), et 549 avec un anneau de type Sweedish adjustable gastric banding (SAGB). En post-operatoire, un transit oesogastrique (TOG) est realise chez tous les patients dans un delai de 24 a 48 heures. A distance, le TOG est realise pour chaque ajustement de l’anneau et pour detecter d’eventuelles complications. Resultats 5 types d’anneaux existants sont presentes. La technique et le materiel de ponction percutanee sous scopie de la chambre implantable sont illustres. Le TOG aux hydrosolubles permet de detecter les complications precoces post- operatoires (perforation gastrique) et des complications plus tardives au niveau de l’anneau (slippage, dilatation chronique de la poche, migration trans-gastrique), au niveau de la tubulure (deconnexion, fuite) et au niveau de la chambre d’injection sous cutanee (infection, bascule). L’ajustement de l’anneau est adapte suivant le retentissement gastrique apres un TOG baryte. Conclusion Dans le traitement de l’obesite morbide l’anneau gastrique, est une technique efficace. La radiologie a un role important dans la detection des complications et dans la prise en charge de la perte ponderale.

Utility of reassessment after neoadjuvant therapy and difficulties in interpretation

We describe the main tools for MR assessment of the response of rectal cancer tumors after chemotherapy, before surgery. In locally advanced cases of rectal and lower rectal cancer, MR is useful in allowing the treatment strategy to be adjusted, enabling conservative surgery to be performed if the patient responds well. The different types of response (fibrous, desmoplastic and colloid), their appearances and difficulties in MR interpretation are described. We describe the features and performance of MR after neoadjuvant therapy for T and N staging, assessment of circumferential resection margin and diffusion weighted imaging. Quantitative (change in tumor volume) and qualitative (grade of tumor response) MR assessment can distinguish good responders from poor responders.

Enlarged adrenals during septic shock

Sir, the hypothalamic-pituitary adrenal axis is an essential part of the host response to infection. It is usually characterized by increased levels of plasma cortisol. Disruption of this endocrine axis may contribute to patients’ worsening from uncomplicated sepsis to multiple organ dysfunction and death [1]. The underlying mechanisms are complex and may include direct damage to the endocrine tissues or interferences between pro-inflammatory mediators or drugs and hormonal metabolism. Subsequently, the hormonal pattern may vary from a syndrome of very low cortisol levels suggestive of impaired synthesis to a syndrome of high cortisol levels suggestive of impaired tissue uptake of cortisol. The following case reports highlight anatomical changes to the adrenals associated with impaired cortisol synthesis in early sepsis.