Pierre Bourgeois

Imaging techniques in the management and prevention of posttherapeutic upper limb edemas

Upper limb edema remains the most frequent complication after treatments for breast carcinoma. Various imaging techniques can be used to prevent these complications, to manage them, and to diagnose the possible lymphonodal evolution that may underlie these events. In the present paper, these techniques are reviewed.

Fluorescence Imaging After Indocyanine Green Injection for Detection of Peritoneal Metastases in Patients Undergoing Cytoreductive Surgery for Peritoneal Carcinomatosis From Colorectal Cancer: A Pilot Study.

Objective: The aim of this study was to evaluate the role of fluorescence imaging (FI) using an intraoperative injection of free indocyanine green (ICG) in the detection of peritoneal metastases (PM) due to colorectal cancer (CRC). Background: A large proportion of patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy will have local recurrence. This is, in part, related to the presence of small undetected nodules in the peritoneal cavity. Near-infrared FI-guided surgery has provided new opportunities for detection of nonvisible lesions during cancer surgery. Methods: Patients with PM from CRC admitted for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy were selected for participation in this study (NCT02032485). Free ICG, at 0.25 mg/kg of patient weight, was intravenous (IV)-injected intraoperatively. Tumor-to-background ratio was calculated for all suspect resected PM. Results: Sixty-three of 78 peritoneal resected nodules in 14 patients were evaluated for fluorescence, among them, 53 were malignant (84%) and 10 benign (16%). Twenty-six were hypofluorescent, 16 moderately hyperfluorescent, and 21 hyperfluorescent. Amongst the 42 nodules of the 9 patients with nonmucinous adenocarcinoma, the mean tumor-to-background ratio was 1.92 (SD 0.67) in malignant and 1.02 (SD 0.06) in benign nodules (P = 0.0099). In 4 of 14 patients (29%), the surgery was modified by intraoperative ICG-FI, which detected additional PM not found using visualization and palpation. Conclusions: This pilot study demonstrates that non-mucinous PM of CRC can be visualized intraoperatively using ICG-FI. Furthermore, ICG-FI findings resulted in modification of the planned surgery in 29% of patients.

Scintigraphic Investigations of the Lymphatic System: The Influence of Injected Volume and Quantity of Labeled Colloidal Tracer

Volumes injected for lymphoscintigraphic investigations are highly variable, and the quantity of labeled colloids injected is usually not reported. The aim of the present study was to evaluate whether and how volume and quantity quantitatively affect lymphoscintigraphic results. Methods: Each of 9 healthy volunteers (4 men and 5 women; mean age, 21 y; range, 19–26 y) participated in 4 lymphoscintigraphic investigations using the same protocol, in which the volume injected was 0.2 or 1.0 mL and the quantity injected was 0.02 or 0.2 mg. Subcutaneous injections of 99mTc-labeled human serum albumin nanosized colloids were placed in the first interdigital space of each foot. Activity at the injection sites and in the inguinoiliac nodes after a standardized sequence of rest, exercise, and normal-activity periods was measured and analyzed as a function of volume and quantity. Results: The highest extraction rate was observed for a quantity of 0.2 mg and a volume of 0.2 mL. This extraction rate was significantly higher than the rates obtained for a quantity of 0.2 mg and a volume of 1.0 mL or for a quantity of 0.02 mg and a volume of 0.2 mL, neither of which differed from the extraction rate for a quantity of 0.02 mg and a volume of 1.0 mL. Activity in inguinoiliac nodes was significantly higher for a quantity of 0.2 mg than for a quantity of 0.02 mg, irrespective of volume. With quantity remaining constant, volume did not influence the activity in inguinoiliac nodes. Conclusion: Both volume and quantity influence the results of lymphoscintigraphic investigations with regard to the quantities extracted from injection sites and the accumulations in nodal regions. Therefore, volume and quantity should be standardized when quantitative parameters are used for diagnostic purposes.

Bicyclist's vulva: observational study

# Bicyclists vulva: observational study {#article-title-2} Many chronic injuries related to athletic bicycling are now recognised: cyclists nipples,1 neuropathic syndromes,2 and skin problems caused by the saddle. We have seen a new clinical problem in female high level cycling competitors: bicyclists vulva (figure). ![][1] Bicyclists vulva Six women, aged 21–38 years, had a unilateral chronic swelling of the labium majus after a few years of intensive bicycling (an average of 462.5 km per week). All six had typical unilateral lymphoedema (five on the right side, one on the left) which was more severe after more intense and longer training. The position of the bicycle saddle, the type of shorts worn, and the womens perineal hygiene were optimum. There was no family history of lymphoedema in any of the women, nor any common factor that might explain the lymphoedema. All six women regularly had inflammatory skin problems related to the saddle and five had scars and perineal lesions such as chafing, perineal folliculitis, and nodules. Further clinical and ultrasound examination showed no pelvic anomaly. Three of the cyclists (aged 27, 21, and 21 years) underwent three phase lymphoscintigraphy of their legs.3 We found similar lymphatic anomalies in all three. One had bilateral intra-abdominal abnormalities at the level of the iliac nodes and functional insufficiency of the superficial lymphatic system on the left side, the same side as the oedematous labium majus. In the other two, who presented … [1]: /embed/graphic-1.gif

Internal mammary lymphoscintigraphy: Current status in the treatment of breast cancer

In the management of breast carcinomas, the internal mammary lymphoscintigraphy represents a simple, nontraumatic and reproducible technique to visualize and investigate the internal mammary nodes. As suggested by the total absence of visualization of nodes on the operated side in all or in the two upper intercostal spaces, internal mammary chain invasion concerns 30% of the population. This frequency increases with the clinical staging of the tumor, its size, and the extent of the disease in the axilla. It is higher for tumors of inner rather than of outer quadrants. When internal mammary lymphoscintigrams are compared in frontal view to the limits of the usual irradiation fields, parasternal nodes outside these limits or in borderline position are observed in 15 to 34% of the population according to the X-ray technique used. Furthermore, 40% of the tangential irradiation fields does not give an adequate irradiation dose to the internal mammary nodes. In one case out of four, IMLSc allows the reduction of useless heart- and lung-irradiated volumes. Internal mammary node invasion as demonstrated by lymphoscintigraphy has been demonstrated to have a prognostic value as the anatomopathological axillary node status, concerning both survival and disease evolution rates. IMLSc, when compared to the other possible investigation techniques of these nodes (X-ray computed tomography, echography or surgery, etc.), represents at the present time the investigation method of choice with the widest implications (diagnostic, therapeutic, and prognostic).

Eighteen months clinical experience with the GeneSearch breast lymph node assay

BACKGROUND The accuracy of a molecular reverse transcriptase-polymerase chain reaction (RT-PCR)-based assay for metastases detection in axillary sentinel lymph nodes (SLNs) has recently been validated in our institution and adopted as an intraoperative test for breast cancer patient management. METHODS Molecular assay performance was compared to standard postoperative histology in 253 consecutive patients with clinically node-negative T1 early breast cancer (<2 cm). RESULTS The molecular assay correctly identified 26/27 macrometastases and 11/15 micrometastases. Overall concordance with histopathology was 93%, with 87% sensitivity, 94% specificity, and 75% positive and 97% negative predictive values. The molecular assay was positive in 13/14 patients with SLNs and nonsentinel lymph node (axillary lymph node [ALN])-positive histology. Notably, 2/12 patients with assay-positive/histology-negative SLNs exhibited ALN positivity. CONCLUSIONS This molecular assay can raise the standard of care for patient management as its accuracy is similar to that of standard postoperative histology with the advantage of being standardized, objective, and fast enough for intraoperative use.

Postoperative axillary lymphoscintigraphy in the management of breast cancer

Postoperative axillary lymphoscintigrams have been performed according to a technique of two-staged injection in 313 patients who had undergone a radical mastectomy with axillary dissection for breast cancer. Total absence of visualization of residual nodes suggests that dissection could be said to be complete in only 35.8% of the investigated patients, or because of metastatic disease causing blockage. The visualized residual nodes in patients represent a risk of developing nodal relapse, especially with positive pathological demonstration of axillary node invasion and without nodal irradiation. On the other hand, when the investigation showed the interruption of the lymphatic pathways of the arm, patients developed upper limb edemas more frequently. It is concluded that this simple and non traumatic technique is of value in order to assess the immediate postoperative axillary nodal status, and that it may influence the treatment of the patients.

Bone marrow scintigraphy in breast cancer.

Bone marrow scintigrams (BMS) have been performed in 101 women with histologically proven breast cancer (36 stage IV among them at the time of the first investigation, follow-up examinations available in 41, disease evolution observed in 17). They have been compared to conventional bone scintigram (CBS) as well as to radiological, clinical, biological and follow-up data obtained in the same patients. Only three (7.4%) out of the 41 patients with radiologically or/and histologically proven skeletal metastasis had normal BMS and 33 had corresponding bone marrow scintigraphic defects (BMS ++). On the other hand, only three patients of the 32 with normal BMS had documented skeletal abnormalities. Abnormal bone marrow extension, observed in 61.4% of the patients (62/101), seems to represent a reaction of the reticulo-endothelial system to the disease dissemination - even microscopic - and, as such, to have prognostic implications. As BMS demonstrated skeletal invasion earlier or more precisely than CBS in ten cases, the technique appears of value and of interest in breast cancer management.

Fluorescence imaging after intraoperative intravenous injection of indocyanine green for detection of lymph node metastases in colorectal cancer.

PURPOSE This short communication aims at reporting the potential role of ICG fluorescence imaging after an intraoperative IV injection in the detection of lymph nodes (LNs) of a colorectal cancer origin. PATIENTS AND METHODS Two patients who were included in a protocol study evaluating the role of ICG in the detection of peritoneal metastases of colorectal origin (Protocol NCT-01995591) also had fluorescent LNs at exploration with a dedicated near-infrared camera system (Photodynamic Eye, PDE; Hamamatsu Photonics, Hamamatsu, Japan). An IV injection of ICG was delivered intraoperatively at 0.25 mg/kg. All LNs were also explored for their fluorescence, and tumor to background ratio (TBR) was calculated with IC-Calc 2.0 program. RESULTS One patient had two retroperitoneal lymph node metastases and one mesocolic on a pre-operative work-up. The three tumoural lymph nodes at histopathology were hyperfluorescent in comparison to other uninvolved LNs. One patient had no pre-operatively known LN metastases and had one epigastric hyperfluorescent LN discovered at intraoperative exploration. This LN of 6 mm in size was malignant at histopathology. CONCLUSION This is the first report about tumoural LN of colorectal cancer origin detected by fluorescence imaging with intraoperative IV free-ICG injection. ICG fluorescence imaging by intraoperative IV injection represents an easy method for detecting metastatic LNs in colorectal cancer. This proof of concept should lead to further research in this field.

Axillary lymphoscintigraphy: current status in the treatment of breast cancer.

Postoperative axillary lymphoscintigraphy has been performed after time-differentiated intercostal and interdigital injections of a 99Tc-labeled sulfur microcolloid in 313 patients suffering from breast cancer who underwent radical surgery with axillary dissection. As demonstrated by the absence of visualized lymph nodes after both injections, the axillary dissection could be considered as complete in only 34.6% of the investigated patients. The greatest part of lymph nodes, remaining after surgery, corresponds to the inferior and central groups (after interdigital injection). In 15% of the cases the intercostal injection leads to the demonstration of external mammary lymph nodes. According to the analysis of 202 cases with at least 1 year follow-up, the existence of visualized residual lymph nodes represents a factor of risk to develop nodal relapse especially in patients with positive peroperative axillary lymph node status who did not receive postoperative X-ray treatment. Upper limb edema occurs in 22.5% of the cases; mainly in patients with negative lymphoscintigraphic findings (demonstrating the interruption of the axillary lymphatic flux) and without nodal irradiation. Postoperative axillary lymphoscintigraphic findings should be evaluated in connection with the peroperative axillary lymph node status as established according to the histological analysis, and should take into account the number of removed lymph nodes. Preoperative axillary lymphoscintigraphy seems to be a less contributive examination technique.