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ObjectiveLiver stiffness measurement (LSM) is a tool used to screen for significant fibrosis and portal hypertension. The aim of this retrospective multicentre study was to develop an easy tool using LSM for clinical outcomes in advanced chronic liver disease (ACLD) patients.DesignThis international multicentre cohort study included a derivation ACLD patient cohort with valid two-dimensional shear wave elastography (2D-SWE) results. Clinical and laboratory parameters at baseline and during follow-up were recorded. LSM by transient elastography (TE) was also recorded if available. The primary outcome was overall mortality. The secondary outcome was the development of first/further decompensation.ResultsAfter screening 2148 patients (16 centres), 1827 patients (55 years, 62.4% men) were included in the 2D-SWE cohort, with median liver SWE (L-SWE) 11.8 kPa and a model for end stage liver disease (MELD) score of 8. Combination of MELD score and L-SWE predict independently of mortality (AUC 0.8). L-SWE cut-off at ≥20 kPa combined with MELD ≥10 could stratify the risk of mortality and first/further decompensation in ACLD patients. The 2-year mortality and decompensation rates were 36.9% and 61.8%, respectively, in the 305 (18.3%) high-risk patients (with L-SWE ≥20 kPa and MELD ≥10), while in the 944 (56.6%) low-risk patients, these were 1.1% and 3.5%, respectively. Importantly, this M10LS20 algorithm was validated by TE-based LSM and in an additional cohort of 119 patients with valid point shear SWE-LSM.ConclusionThe M10LS20 algorithm allows risk stratification of patients with ACLD. Patients with L-SWE ≥20 kPa and MELD ≥10 should be followed closely and receive intensified care, while patients with low risk may be managed at longer intervals.

International audience; Purpose: Psammocarcinoma (PK) is a rare disease of unknown origin. We aimed to report the characteristics, management and survival of patients operated on for PK within the French Network for Rare Peritoneal Malignancies (RENAPE) expert centers.Patients and methods: All consecutive cases of PK operated within all 26 RENAPE centers between 1997 and 2018 were retrospectively analyzed.Results: Twenty-five patients were identified. The median age was 53 years [range 17–78]. None of the patients had extra peritoneal metastases at diagnosis. A median of 6 cycles of carboplatin-based systemic chemotherapy was delivered in 52% preoperatively (n = 13) and 56% postoperatively (n = 14); associated with placlitaxel for 12 patients. All patients were operated on. The median PCI was 23 [0–33]. Eighty-four percent had a complete cytoreductive surgery through digestive (n = 7), spleen (n = 3), pancreas (n = 1) resections and/or multiple peritonectomies (n = 11). Five patients (20%) had intraperitoneal chemotherapy. Morbidity (Dindo-Clavien ≥3) was 12%. No postoperative death occurred. After a median follow-up of 42 months (range [2–194]), the median overall (OS) and progression-free (DFS) survival times were respectively 128 months and 31 months. Eighteen patients recurred (72%), mainly in the peritoneum (n = 16). Four of them (22%) were reoperated. The 5 and 10-year DFS rates were both 20.3%. The 5 and 10-year OS rates were 62% and 51.7%, respectively. A complete cytoreductive surgery was associated with a better OS and DFS in a univariate analysis.Conclusion: Complete cytoreductive surgery is the cornerstone of the PK's management as a primary treatment. Recurrence remains common and new adjuvant strategies seem needed.

[DOI:\hrefhttps://dx.doi.org/10.1016/j.ejrad.2015.07.02910.1016/j.ejrad.2015.07.029] [PubMed:\hrefhttps://www.ncbi.nlm.nih.gov/pubmed/2629932326299323]; This study assessed the clinical usefulness of shear wave elastography (SWE) during ultrasound for differentiating between focal nodular hyperplasias (FNHs) and hepatocellular adenomas (HAs).\ SWE was performed on 56 patients presenting with 76 liver lesions (57 FNHs and 19HAs) that were confirmed by MRI and contrast-enhanced ultrasound (CEUS) (n=55) or by histology (n=21). A mean elasticity value was obtained for each lesion. The ratios of the elasticity of the lesions to the elasticity of the surrounding liver were determined. The optimal elasticity cut-off value for distinguishing between the two lesion types was determined using ROC analysis. All lesions that were classified as "undetermined" after CEUS were reclassified using the elasticity values.\ The mean elasticity value was 46.99 ± 31.15 kPa for FNHs and 12.08 ± 10.68 kPa for HAs (p

Two-dimensional shear wave elastography (2D-SWE) has proven to be efficient for the evaluation of liver fibrosis in small to moderate-sized clinical trials. We aimed at running a larger-scale meta-analysis of individual data. Centers which have worked with Aixplorer ultrasound equipment were contacted to share their data. Retrospective statistical analysis used direct and paired receiver operating characteristic and area under the receiver operating characteristic curve (AUROC) analyses, accounting for random effects. Data on both 2D-SWE and liver biopsy were available for 1,134 patients from 13 sites, as well as on successful transient elastography in 665 patients. Most patients had chronic hepatitis C (n = 379), hepatitis B (n = 400), or nonalcoholic fatty liver disease (n = 156). AUROCs of 2D-SWE in patients with hepatitis C, hepatitis B, and nonalcoholic fatty liver disease were 86.3%, 90.6%, and 85.5% for diagnosing significant fibrosis and 92.9%, 95.5%, and 91.7% for diagnosing cirrhosis, respectively. The AUROC of 2D-SWE was 0.022-0.084 (95% confidence interval) larger than the AUROC of transient elastography for diagnosing significant fibrosis (P = 0.001) and 0.003-0.034 for diagnosing cirrhosis (P = 0.022) in all patients. This difference was strongest in hepatitis B patients. Conclusion: 2D-SWE has good to excellent performance for the noninvasive staging of liver fibrosis in patients with hepatitis B; further prospective studies are needed for head-to-head comparison between 2D-SWE and other imaging modalities to establish disease-specific appropriate cutoff points for assessment of fibrosis stage. (Hepatology 2018;67:260-272).

Objective: The purpose of this study was to demonstrate that the median door-to-needle (DTN) time for intravenous tissue plasminogen activator (tPA) treatment can be reduced to 45 min in a primary stroke centre with MRI-based screening for acute ischaemic stroke (AIS). Methods: From February 2015 to February 2017, the stroke unit of Perpignan general hospital, France, implemented a quality-improvement (QI) process. During this period, patients who received tPA within 4.5 h after AIS onset were included in the QI cohort. Their clinical characteristics and timing metrics were compared each semester and also with those of 135 consecutive patients with AIS treated by tPA during the 1-year pre-QI period (pre-QI cohort). Results: In the QI cohort, 274 patients (92.5%) underwent MRI screening. While the demographic and baseline characteristics were not significantly different between cohorts, the median DTN time was significantly lower in the QI than in the pre-QI cohort (52 vs. 84 min; p < 0.00001). Within the QI cohort, the median DTN time for each semester decreased from 65 to 44 min (p < 0.00001) and the proportion of treated patients with a DTN time ≤45 min increased from 25 to 58.9% (p < 0.0001). Overall, DTN time improvement was associated with a better outcome at 3 months (patients with a modified Rankin Scale score between 0 and 2: 61.8% in the QI vs. 39.3% in the pre-QI cohort; p < 0.0001). Conclusions: A QI process can reduce the DTN within 45 min with MRI as a screening tool.

To evaluate morphological and perfusion changes in liver metastases of neuroendocrine tumours by contrast-enhanced ultrasound (CEUS) after transarterial embolisation with bead block (TAE) or trans-arterial chemoembolisation with doxorubicin-eluting beads (DEB-TACE). In this retrospective study, seven patients underwent TAE, and ten underwent DEB-TACE using beads of the same size. At 1 day before embolisation, 2 days, 1 month and 3 months after the procedure, a destruction-replenishment study using CEUS was performed with a microbubble-enhancing contrast material on a reference tumour. Relative blood flow (rBF) and relative blood volume (rBV) were obtained from the ratio of values obtained in the tumour and in adjacent liver parenchyma. Morphological parameters such as the tumour’s major diameter and the viable tumour’s major diameter were also measured. A parameter combining functional and morphological data, the tumour vitality index (TVI), was studied. The Wilcoxon rank-sum test and Fisher’s test were used to compare treatment groups. At 3 months rBF, rBV and TVI were significantly lower (P = 0.005, P = 0.04 and P = 0.03) for the group with doxorubicin. No difference in morphological parameters was found throughout the follow-up. One parameter, TVI, could evaluate the morphological and functional response to treatments. • Contrast-enhanced ultrasound provides morphological and functional information about neuroendocrine hepatic metastases • CEUS can evaluate changes after transarterial chemoembolisation, transarterial-embolisation and transarterial radioembolisation • Functional (but not morphological) imaging reveals differences between TAE and DEB-TACE therapy • To combine morphological and functional parameters, a tumour vitality index is proposed • TVI can be used to monitor treatments acting on tumour vascularisation

Objective: To compare multidetector-row computed tomographic (MDCT) enterography with magnetic resonance (MR) enterography performed upon acute exacerbation of Crohn’s disease. Subjects and Methods: Fifty-seven patients (mean age 33.5) with proven Crohn’s disease and symptoms suggesting acute exacerbation were prospectively included. After oral administration of 1–2 liters of 5% methylcellulose, MDCT and MR enterography were performed on each patient (mean delay Results: MDCT enterography demonstrated fewer artifacts than MR enterography (p < 0.0001). In 48 MDCT/MR enterography examinations, active disease was demonstrated: abscesses (n = 11), fistulas (n = 13), stenoses (n = 23) and/or intestinal inflammation (n = 38). Observers’ agreement (range 0.56–0.87) was not significantly different between MDCT and MR enterography, neither in terms of sensitivity (range 58–95%) nor specificity (range 67–100%) for each of the 8 pathological features. Conclusion: Statistically, MR enterography is of similar diagnostic value as MDCT enterography for acute complications of Crohn’s disease. Since the typical Crohn’s disease patient is young and will very likely undergo life-long imaging, and given concerns about radiation exposure with MDCT, MR enterography should be the preferred modality.

Purpose: To compare entero-MDCT with entero-MRI performed for suspicion of acute exacerbation of known Crohn's disease. Methods and Materials: Fifty-seven patients (mean age 33.5) with histologically proven Crohn's disease were prospectively included. They presented with clinical symptoms suggesting acute exacerbation to the emergency department. After oral administration of 1-2 l of 5% methylcellulosis (+syrup), entero-MDCT and entero- MRI were performed on each patient (mean delay 1 day). Three experienced radiologists blindly and independently evaluated each examination for technical quality, eight pathological CT features (bowel wall thickening, pathological wall enhancement, stenosis, lymphadenopathy, mesenteric haziness, intraperitoneal fluid, abscess, fistula) and final main diagnosis. Interobserver agreement kappa was calculated. Sensitivity and specificity resulted from comparison with the reference standard, consisting of operation (n= 30) and long-time follow-up in case of conservative treatment (n=27). Results: Entero-MDCT demonstrated considerably less artefacts than entero-MRI (p 0.0001). In 9 entero-MDCT/-MRI, no activity of Crohn's disease was seen, whereas in 48 entero-MDCT/-MRI active disease could be demonstrated, such as intraperitoneal abscesses (n=11), fistulas (n=13), stenoses (n=23), acute (n=15) or chronic (n=23) inflammation. Interobserver agreement of the three readers was not significantly different between entero-MDCT and -MRI, neither was sensitivity (range 60-89%) and specificity (range 75-100%) for each of the eight pathological features or for the main diagnosis. Conclusion: Entero-MRI is statistically of similar diagnostic value as entero-MDCT for acute complications of Crohn's disease. Therefore, entero-IRM, devoid of harmful irradiation, should become the preferred imaging modality, since we deal with young patients, very likely exposed to frequent imaging controls in the future.

Many acute and chronic lung diseases are characterized by diffuse infiltration of the lung parenchyma. High-resolution computed tomography (CT) has been widely accepted as the imaging standard of reference for the assessment of these diseases. However, only approximately 10% of the lung parenchyma is scanned with high-resolution CT, and characteristic foci of disease may be missed. With use of the established characteristic high-resolution CT patterns, multi-detector row chest CT has revolutionized the evaluation of diffuse lung disease. Multi-detector row CT generates isotropic volumetric high-resolution data, allowing contiguous three-dimensional (3D) visualization of the lung parenchyma, with the capacity to create high-quality two-dimensional (2D) and 3D reformatted images. Minimum intensity projection is the postprocessing technique of choice for the detection and characterization of most patterns of diffuse lung disease. Maximum intensity projection (MIP) allows the detection and characterization of micronodules; the recognition of enlarged pulmonary veins, which is extremely useful in the diagnosis of pulmonary edema and the assessment of mosaic perfusion; and differentiation between perilymphatic, miliary, and centrilobular distribution. MIP can also help differentiate between constrictive bronchiolitis and mixed emphysema. Two-dimensional reformatted images are now of equal importance with the 2D axial images in diagnosing specific diffuse lung diseases. In the future, 3D reformatted images may be used to help quantify these disorders.

The aim of this retrospective study was to evaluate the prognostic value of different scores (including Child-Pugh and Model for End Stage Liver Diseases) in cirrhotic patients treated with transjugular intrahepatic porto-systemic shunt for refractory ascites.Overall, 111 patients with transjugular intrahepatic porto-systemic shunt insertion between January 1998 and July 2012 were included.Survival rates (without transplantation) were 82.0% at 3 months, and 59.4% at 1 year. In addition to standard parameters, a new simple classification based on platelet count and glomerular filtration rate showed strong prognostic ability and could distinguish 3 groups of patients (Log-rank test, p0.001): a "good-prognosis" group with platelet counts above 125×10(9)L(-1) and a glomerular filtration rate above 90 mL/min (1-year survival rate 92%), a "poor-prognosis" group with platelet counts below 125×10(9)L(-1) and a glomerular filtration rate below 90 mL/min (1-year survival rate 34.8%), and an "intermediate-prognosis" group (1-year survival rate 58.2%). Multivariate analysis showed a hazard ratio of 6.34 for the intermediate class and of 12.623 for the high class.A new and simple classification including platelet count and glomerular filtration rate is highly predictive of survival in patients with refractory ascites treated with transjugular intrahepatic porto-systemic shunt and could be used to select patients for this procedure.

To determine the elasticity characteristics of focal liver lesions (FLLs) by shearwave elastography (SWE). We used SWE in 108 patients with 161 FLLs and in the adjacent liver for quantitative and qualitative FLLs stiffness assessment. The Mann–Whitney test was used to assess the difference between the groups of lesions where a P value less than 0.05 was considered significant. SWE acquisitions failed in 22 nodules (14 %) in 13 patients. For the 139 lesions successfully evaluated, SWE values were (in kPa), for the 3 focal fatty sparings (FFS) 6.6 ± 0.3, for the 10 adenomas 9.4 ± 4.3, for the 22 haemangiomas 13.8 ± −5.5, for the 16 focal nodular hyperplasias (FNHs) 33 ± −14.7, for the 2 scars 53.7 ± 4.7, for the 26 HCCs 14.86 ± 10, for the 53 metastasis 28.8 ± 16, and for the 7 cholangiocarcinomas 56.9 ± 25.6. FNHs had significant differences in stiffness compared with adenomas (P = 0.0002). Fifty percent of the FNHs had a radial pattern of elevated elasticity. A significant difference was also found between HCCs and cholangiocarcinomas elasticity (P = 0.0004). SWE could be useful in differentiating FNHs and adenomas, or HCCs and cholangiocarcinomas by ultrasound. • Elastography is becoming quite widely used as an adjunct to conventional ultrasound • Shearwave elastography (SWE) could help differentiate adenomas from fibrous nodular hyperplasia • SWE could also be helpful in distinguishing between hepatocellular carcinomas and cholangiocarcinomas • SWE could improve the identify hepatocellular carcinomas in cirrhotic livers

International audience; In ultrasound contrast imaging, many techniques based on multiple transmissions have been proposed to increase the contrast-to-tissue ratio (CTR). They are generally based on the response of static scatterers inside the imaged region. However, scatterer motion, for example in blood vessels, has an inevitable influence on multi-pulse techniques, which can either enhance or degrade the technique involved. This paper investigates the response of static nonlinear media insonated by multi-pulses with various phase shifts, and the influence of scatterer motion on multi-pulse techniques. Simulations and experimental results from a single bubble and clouds of bubbles show that the phase shift of the echoes backscattered from bubbles is dependent on the transmissions' phase shift, and that the bubble motion influences the efficiency of multi-pulse techniques: fundamental and second-harmonic amplitudes of the processed signal change periodically, exhibiting maximum or minimum values, according to scatterer motion. Furthermore , experimental results based on the second-harmonic inversion (SHI) technique reveal that bubble motion can be taken into account to regulate the pulse repetition frequency (PRF). With the optimal PRF, the CTR of SHI images can be improved by about 12 dB compared with second-harmonic images.

To describe the early patterns of liver lesions successfully treated with radiofrequency ablation (RFA) or cryoablation (CA) and their changes over time. Twenty-two RFA-treated and 17 CA-treated patients underwent CEUS from week 1 to year 3 post-ablation. Patterns, margins and volumes of RF-induced and cryolesions were evaluated and compared over time. After contrast enhancement, shortly after ablation, undefined margins with persistent enhancing small vessels penetrating >2 mm into the treated zone were significantly more frequent after CA (67 %) than RFA (22 %) (P

We studied correlation and agreement between perfusion parameters derived from contrast-enhanced ultrasonography (CEUS) and computed tomography (CT). Both techniques were performed in 16 patients with proven liver metastases from endocrine tumor. Replenishment study after ultrasound-induced destruction of microbubbles was used for CEUS quantification. CEUS-derived relative values of blood flow, blood volume and mean transit time were compared with perfusion CT-derived parameters measured in the same tumors. Significant correlation was observed between CEUS normalized values and CT absolute tumor values for blood flow (r = 0.58; p = 0.018), blood volume (r = 0.61; p = 0.012) and mean transit time (r = 0.52; p = 0.037). Correlation was not significant for non-normalized values. Agreement between CEUS normalized values and perfusion CT relative values was significant (p0.04). Estimated bias between CEUS and CT for relative perfusion values was -1.38 (-5.02; 2.27) for blood flow, +0.26 (-0.79; 1.31) for blood volume and +0.21 (-0.46; 0.87) for mean transit time. We conclude that normalization markedly increased correlation between CEUS- and CT-derived perfusion values and allowed agreement assessment.

International audience

To determine, by using contrast material-enhanced ultrasonography (US), how quickly renal tumors grafted in mice begin to revascularize after stopping bevacizumab treatment.All experiments were approved by the regional ethics committee. A human tumor cell line SK-NEP-1 was grafted at day 0 in the left kidney of 50 nude mice. Forty-two mice developed tumors and longitudinal follow-up was performed on 32 surviving mice. From day 13, 14 controls received biweekly saline; 11 mice received biweekly bevacizumab until day 35 (continuous); and seven received biweekly bevacizumab until day 22, then biweekly placebo until day 35 (discontinued). Contrast-enhanced US was performed on days 13, 14, 22, 27, and 35. Once the injected contrast material distribution reached an equilibrium phase, high-acoustic pressure pulses were applied to destroy microbubbles in the capillary bed in the imaged plane. Reperfusion was monitored, and time-signal intensity (SI) curves were obtained from the linear average of SIs in intratumoral and matched-depth renal cortex regions of interest. A kinetic parameter calculated from reperfusion curves reflects local perfusion, normalized with respect to adjacent renal cortex perfusion. Normalized perfusion obtained from each group was compared with that from the other groups and with necrosis percentages and microvascular density assessed histologically at day 35. Comparisons were made by using analyses of variance and Tukey-Kramer tests.The lowest excised mean tumor weights (+/- standard deviation) corresponded to the longest bevacizumab-treatment duration: 1.4 g +/- 1.1 (continuous-treatment) compared with 2.3 g +/- 2.1 (discontinued) and 3.7 g +/- 1.9 (control) (P = .01). On day 35, the respective control and continuously treated groups had comparable and significantly larger necrotic areas: 37% +/- 14 and 32% +/- 17 larger than the discontinued-treatment group (15% +/- 9; P.05). Normalized perfusion increased significantly with time (P = .02) in the discontinued-treatment group after therapy ceased (day 22).Noninvasively measured contrast-enhanced US parameters demonstrated tumor revascularization after stopping antiangiogenic therapy in this murine tumor model.

OBJECTIVE Endocrine tumors of the ampullary region are rare, and accurate indications for their management are lacking. We aimed to evaluate the outcome of surgical treatment in this indication. METHOD We reviewed all patients who submitted to a pancreaticoduodenectomy for ampullary endocrine tumors between 1982 and 2003 in our center. RESULTS Eight patients, 3 men and 5 women, with a mean age of 47.8 years (range, 37-57 years) were included. Two patients presented with Zollinger-Ellison syndrome, and 1 had neurofibromatosis. Operative mortality was nil. The mean size of the tumors was 17.4 mm (range, 5-40 mm). There were 7 well-differentiated and 1 poorly differentiated endocrine carcinomas. Seven patients had satellite lymph node metastases, and 1 had diffuse liver metastases. Median follow-up was 131 months (range, 17-315 months). At the end of the follow-up period, 5 patients were alive and disease-free; 1 patient was alive with stable liver metastases. Two patients died 17 months and 13 years after surgery, respectively, from metastasis and an unrelated cause. CONCLUSION This study demonstrates the high frequency of lymph node invasion in these uncommon tumors, even at an early clinical stage. Pancreaticoduodenectomy may result in prolonged survival of patients with well-differentiated tumors.

Since 2004, four antiangiogenic drugs have been approved for clinical use in patients with advanced solid cancers, on the basis of their capacity to improve survival in phase III clinical studies. These achievements validated the concept introduced by Judah Folkman that the inhibition of tumor angiogenesis could control tumor growth. It has been suggested that biomarkers of angiogenesis would greatly facilitate the clinical development of antiangiogenic therapies. For these four drugs, the pharmacodynamic effects observed in early clinical studies were important to corroborate activities, but were not essential for the continuation of clinical development and approval. Furthermore, no validated biomarkers of angiogenesis or antiangiogenesis are available for routine clinical use. Thus, the quest for biomarkers of angiogenesis and their successful use in the development of antiangiogenic therapies are challenges in clinical oncology and translational cancer research. We review critical points resulting from the successful clinical trials, review current biomarkers, and discuss their potential impact on improving the clinical use of available antiangiogenic drugs and the development of new ones.

Microvascularization modifications should precede tumor size‐changes during anti‐angiogenic therapy. We applied contrast functional ultrasound imaging (fUSI) to detect changes in Wilms tumors with anti‐angiogenic treatment (Bevacizumab). Human Wilms tumor cells was grafted in left kidney of 32 mice. Once tumors had >5mm diameter, mice received : placebo, N=14; Bevacizumab for 21days, N=11; and Bevacizumab for 10days followed by placebo for 11days, N = 7. On days ‐1, +1, +9, +14 and +21 with respect to treatment start, fUSI was performed (CPS mode, SonoVue). Linear time intensity curves were obtained from regions in kidney cortex and matched‐depth of tumor for first bolus passage and 50s following acoustic destruction of contrast. Excised tumor weight decreased with increased treatment duration: 3.7+/‐1.8 g (placebo), 2.3+/‐1.9 g (Bevacizumab‐10days, placebo‐11days), 1.4+/‐0.7 g (Bevacizumab‐21 days) [p

Objectif : l’objectif de cette étude était de comparer rétrospectivement la thermo-ablation par micro-ondes (MO) et par radiofréquence (RF) dans le traitement percutané des tumeurs pulmonaires primitives et secondaires.Matériels et méthodes : 115 patients présentant un total de 160 tumeurs pulmonaires (primitives, n = 41 ; secondaires, n = 119) ont été inclus rétrospectivement. 56 hommes et 59 femmes, présentant un âge moyen de 67,8 ± 12,7 (DS) ans (étendue : 42-89 ans) ont été traités par MO (61 patients ; 79 tumeurs) ou par RF (54 patients ; 81 tumeurs). Les critères d'évaluation principaux de l'étude étaient la survenue de récidive locale au cours du suivi et l'incidence des complications pendant et après thermo-ablation. Les groupes MO et RF ont été comparés en termes d'efficacité du traitement et de taux de complications.Résultats : les caractéristiques démographiques étaient comparables dans les deux groupes. Le diamètre tumoral moyen était plus petit dans le groupe RF (13,1 ± 5,1 mm; 4-27 mm) que dans le groupe MO (17,1 ± 8,3 mm ; 5-36 mm) (P