[Contribution of curative and preventive embolization for renal angiomyolipomas treatment]

OBJECTIVE

The purpose of this study was to present the role of embolization in the treatment of kidney angiomyolipomas (AML), for preventive care or in case of bleeding.

METHODS

From March 1995 to March 2007, 22 AML in 21 patients (16 women and five men, mean age 38 years) were embolized: five AML were treated for hemorrhagic shock emergency and 16 were preventive embolization. Eight AML were discovered incidentally and nine patients had pain or hematuria. The average size of AML was 70 mm (20 to 130 mm). The embolization was performed with coils or embospheres.

RESULTS

Three patients have not been embolized because of renal failure catheterization. The embolization was effective in 100% of patients treated in emergency. The six patients cared for gross hematuria and pain were asymptomatic after embolization. The average tumor size reduction was 32% with a mean time of 53.2 months (five to 101 months). Three patients (14%) have benefited from surgery remotely.

CONCLUSION

Embolization is the best technique for treating bleeding secondary to AML. In preventive treatment or symptomatic, AML embolization is a treatment to offer before considering surgery.

[Adrenal hemorrhage acutised by adrenocorticotropin hormone]

OBJECTIVE

Many spontaneous adrenal hematomas have been observed in patients being treated by Synacthène. The purpose of this study is to define how to take those patients in charge on a short-, mid- and long-term.

PATIENTS AND METHODS

From January 2000 to December 2008, five patients (four males and one female), mean age 47, were taken in charge in our service for spontaneous adrenal hematomas. All those patients had been treated with Synacthène for a mid-sciatic pain for 72 hours. We associated a clinical, endocrine and radiologic staging to treat those patients.

RESULTS

Four patients underwent a watchful waiting, only one patient needed surgery. No adrenal tumor was ever found during the mean two years follow-up (one to four). Two patients suffered of the condition of the antiphospholipid syndrome.

CONCLUSION

Spontaneous adrenal hematomas are a most uncommon pathology. The clinical attitude has thus to be defined clearly. The patient must be under close clinical evaluation. Biological and morphological parameters have to be often repeated. An adrenal tumor has to be excluded by the evaluation, as that tumor could be secreting or could not be secreting. Antiphospholipid syndrome must also be excluded.

[Chylous ascites after trans-peritoneal laparoscopic adrenalectomy: anatomical distribution of lymph nodes and management]

We report the case of a chylous ascites after transperitoneal laparoscopic adrenalectomy. This complication is known after surgery in urology but remains rare and was not described after laparoscopic adrenalectomy. Anatomy for lymph nodes distribution was described to understand the occurrence of this complication. The diagnosis of chylous ascites is referred to clinical signs of peritoneal irritation and confirmed by puncture, the treatment is initially conservative.

Endogenous hepatocyte growth factor is a niche signal for subventricular zone neural stem cell amplification and self-renewal

Neural stem cells persist in the adult mammalian brain, within the subventricular zone (SVZ). The endogenous mechanisms underpinning SVZ neural stem cell proliferation, self-renewal, and differentiation are not fully elucidated. In the present report, we describe a growth-stimulatory activity of liver explant-conditioned media on SVZ cell cultures and identify hepatocyte growth factor (HGF) as a major player in this effect. HGF exhibited a mitogenic activity on SVZ cell cultures in a mitogen-activated protein kinase (MAPK) (ERK1/2)-dependent manner as U0126, a specific MAPK inhibitor, blocked it. Combining a functional neurosphere forming assay with immunostaining for c-Met, along with markers of SVZ cells subtypes, demonstrated that HGF promotes the expansion of neural stem-like cells that form neurospheres and self-renew. Immunostaining, HGF enzyme-linked immunosorbent assay and Madin-Darby canine kidney cell scattering assay indicated that SVZ cell cultures produce and release HGF. SVZ cell-conditioned media induced proliferation on SVZ cell cultures, which was blocked by HGF-neutralizing antibodies, hence implying that endogenously produced HGF accounts for a major part in SVZ mitogenic activity. Brain sections immunostaining revealed that HGF is produced by nestin-expressing cells and c-Met is expressed within the SVZ by immature cells. HGF intracerebroventricular injection promoted SVZ cell proliferation and increased the ability of these cells exposed in vivo to HGF to form neurospheres in vitro, whereas intracerebroventricular injection of HGF-neutralizing antibodies decreased SVZ cell proliferation. The present study unravels a major role, both in vitro and in vivo, for endogenous HGF in SVZ neural stem cell growth and self-renewal.

[Non-Hodgkin's primitive lymphoma of the testis: long-term prognosis associated with treatment combining systemic and intrathecal chemotherapy]

OBJECTIVES

To evaluate the long-term prognosis of a retrospective series of primitive malignant non-Hodgkin's lymphoma (MNHL) of the testicle treated by orchidectomy and combined systemic and intrathecal chemotherapy.

PATIENTS AND METHODS

From 1992 to 2006, eight consecutive patients were treated for a primitive MNHL of the testicle (stages : IA [n=1], IEA [n=5], IIEA [n=1], IVEA [n=1]) and retrospectively analyzed. All of these tumors were highly malignant. The average age of the patients at the time of diagnosis was 64 years old (46-78). All the patients benefited from an enlarged orchidectomy and received a combination of systemic and intrathecal CHOP and VACP chemotherapy. Six patients finished with some locoregional radiotherapy and three had cerebral radiotherapy.

RESULTS

Patients were treated over an average period of 90.5 months (12 to 168 months). Five patients (62.5%) responded successfully, one patient had a cerebral relapse stabilized by a second course of chemotherapy. Three patients died, one from septic shock during chemotherapy (IVEA stage), another from mesenteric infarction (IAE stage) and the third from acute coronary thrombosis while in complete remission.

CONCLUSION

In spite of a reputedly bleak prognosis, primitive MNHL of the testicle treated with a combination of systemic and intrathecal chemotherapy would seem to be associated with a good specific long-term survival. Unfortunately, the rate of mortality linked to chemotherapy is significant (close to 12.5% in our series) and would not appear to entirely protect against cerebral recurrence.

Sensory-motor polyradiculoneuropathy as the first manifestation of sternum bone plasmacytoma only revealed by bone scintigraphy

Bone plasmacytoma is a rare plasma cell neoplasm that can present with a polyradiculoneuropathy. A 57-year-old man presented with 2-month history of progressive weakness and numbness of both legs. Neurological examination showed symmetric distal weakness, reduced vibration senses in limbs and areflexia. CSF had high protein content. Electrophysiological evaluation revealed a demyelinating sensory-motor polyneuropathy. IgG-lambda paraprotein was present in serum. Full skeletal survey, spinal MRI and body CT-scan were normal. 99mTc-methylene-dyphosphonate scintigraphy (99mTc-MDP) revealed a solitary accumulation in the sternum. Biopsy of the lesion demonstrated a plasmacytoma. We emphasize that 99mTc-MDP scintigraphy can be a useful screening procedure for patients with polyradiculoneuropathy and occult bone plasmacytoma.

[Place of serum HCG assay in the follow-up of non-HCG-secreting testicular seminomas]

OBJECTIVE

Human chorionic gonadotrophin (HCG) is secreted by 10 to 20% of seminomas. The authors evaluated variations of serum total HCG levels in patients with normal baseline levels for the surveillance of treated testicular seminomas in order to determine the value of assay of this tumour marker in the follow-up of testicular seminoma.

PATIENTS AND METHODS

Retrospective study from January 1988 to March 2007, including 95 cases of operated testicular cancer, including 28 seminomas, 25 of which did not secrete HCG (baseline total HCG less than 15 IU/L). Patients were reviewed periodically: every three months for one year, every six months during the second year, then annually, comprising of clinical examination, CT examination and assay of tumour markers (HCG, LDH and AFP).

RESULTS

Mean follow-up was 77.5 months (range: 6-120). Twenty-five patients had a total HCG level less than 15 IU/L three months after orchidectomy. Serum HCG remained stable at less than 15 IU/L in all patients with a follow-up of more than three years. Two patients developed non-regional lymph node recurrence with no modification of the serum HCG level.

CONCLUSION

All treated non-HCG-secreting seminomas with or without recurrence had stable and normal HCG levels throughout follow-up, which raises the question of the value of HCG assay in the follow-up of these patients following histological confirmation of the diagnosis.

[Laparoscopy technical tip: inexpensive scope holder]

The authors have created a reproducible laparoscope holder that is 150 euros less expensive, which can be used to perform laparoscopic radical prostatectomy and sacral colpopexy with a single assistant and four free hands. One hundred and sixteen procedures were performed with this original, compact and easy to use apparatus. The characteristics of this scope holder allow mobilization of the camera in three dimensions and maintenance of a fixed image after positioning. This laparoscope holder provides an economic solution that can be used in all laparoscopy units and which liberates the assistant's two hands.

[Ureter drugs]

Many improvements have been made recently in the field of the ureteral smooth muscle pharmacology. After a brief summary on physiological basis, we review what is known about effects on ureter of different drugs class. In a second part, we review clinical applications for renal colic analgesia, calculi expulsive medical therapy, ESWL adjuvant treatment and preoperative treatment before retrograde access. There are now sufficient data on NSAID and alpha-blockers. beta-agonists, especially for beta3 selective ones, and topical drugs before retrograde access are interesting and should be further evaluated.

Prevalence of patent foramen ovale and usefulness of percutaneous closure device in carcinoid heart disease

The aim of this study was to assess (1) the incidence of patent foramen ovale (PFO) in carcinoid syndrome (CS) and (2) the feasibility of percutaneous closure procedure in selected patients with CS. One hundred eight patients were prospectively studied: 54 with CS and an age- and gender-matched control group. All patients underwent conventional and contrast echocardiography. Patients with clinical signs of dyspnea (New York Heart Association class > or =III), cyanosis, carcinoid heart disease (CHD), and severe PFO were referred for the percutaneous closure of PFO. The prevalence of PFO was 41% in patients with CS and 22% in the control group (p = 0.03) and was significantly higher in patients with CHD (59%, p = 0.009). Four patients (14% of those with CHD) were referred for the percutaneous closure of PFO, and 3 patients ultimately underwent PFO closure (using Amplatzer septal occluders). At 6-month follow-up, New York Heart Association class was improved in all patients, as well as arterial blood gas results (p = 0.04) and 6-minute walking distance (p = 0.03), but all patients presented residual right-to-left shunts. In conclusion, this prospective study demonstrates that in patients with CHD, the prevalence of PFO is high and that percutaneous closure of PFO is feasible, with a reduction in symptoms but with residual shunting.

Kinematic and electromyographic analysis of rising from a chair during a "Sit-to-Walk" task in elderly subjects: role of strength

BACKGROUND

With aging, the deterioration of the ability to rise from a chair constitutes a major source of disability and a factor contributing to the loss of autonomy. The aim of this study was to describe kinematic and electromyographic characteristics of rising from a chair during a Sit-to-Walk task and to investigate the relationships between lower limb muscle strength and Sit-to-Walk characteristics.

METHODS

Twenty-four healthy elderly subjects (mean age: 73.8 (6.4) years) were included. The task analyzed consisted in standing up and taking a step. Kinematic data were obtained using a 3D motion analysis software. Surface electromyography of eight lower limb muscles was recorded. Isokinetic strength of ankle plantar flexor and knee flexors and extensors was evaluated.

FINDINGS

The Sit-to-Walk was divided into four phases. For 19 subjects, this task can be considered as a continuum with an overlap of the phases. In comparison with the Sit-to-Stand description, the Sit-to-Walk transition phase, which combined trunk flexion and knee extension, appeared longer in order to increase the body forward transfer for gait initiation. In most cases, the tibialis anterior and peroneus longus muscles were first activated. The isokinetic strength of the knee extensors was negatively correlated with the amplitude of trunk flexion and the knee flexors/extensors torque ratio was correlated with the length of this phase.

INTERPRETATION

Characterization of Sit-to-Walk movement provides information about the ability to rise from a chair. In the elderly, a better knowledge of its determinants could lead to improve strategies for rehabilitation of this critical task.

Evidence for a major role of endogenous fibroblast growth factor-2 in apoptotic cortex-induced subventricular zone cell proliferation

In the adult mammalian brain, neural stem cells persist in the subventricular zone (SVZ) of lateral ventricles. It is well established that cortical damage leads to SVZ cell proliferation and neuronal differentiation. We have previously demonstrated in rat that, when treated with the apoptosis-inducing agent staurosporine, cortex explants release heat-labile factors that promote SVZ cell culture proliferation. In the present report, we investigated in vitro mechanisms involved in cortex injury-triggered neurogenesis in the rat. We demonstrated, using immunoblotting analysis and fibroblast growth factor (FGF)-2 enzyme-linked sandwich immunosorbent assay, that treatment of cortex explants with apoptosis-inducing agents increases the release of FGF-2. We next determined the effects of apoptotic cortex-released factors in regulating SVZ cell proliferation and neuronal differentiation by using bromodeoxyuridine incorporation and microtubule-associated protein 2 immunostaining assays, respectively. We found that conditioned media derived from staurosporine-treated cortex explants enhanced SVZ cell culture proliferation and differentiation by over 50 and 80%, respectively. Finally, we showed that immunodepletion of FGF-2 or pharmacological blockade of FGF-2 receptor by SU5402 completely abolished staurosporine-treated cortex mitogenic activity on SVZ cultures but did not alter its activity on neuronal cell differentiation. Altogether, the present report establishes that the release of endogenous FGF-2 by apoptotic cortex explants plays a major role in the induction of SVZ cell proliferation but not neuronal differentiation, which probably depends on the release of other as yet unidentified cortical factors.

Continuous-wave and femtosecond laser operation of Yb:CaGdAlO4 under high-power diode pumping

We demonstrate the generation of 68 fs secant hyperbolic pulses at a 105 MHz repetition rate with an average power of 520 mW from a diode-pumped Yb(3+):CaGdAlO(4) mode-locked laser. A semiconductor saturable absorber allows passive mode locking, and a 15 W diode laser is used to pump directly the crystal. To our knowledge this represents the highest average power ever obtained for a sub-100 fs diode-pumped Yb-bulk laser.

[Endovascular treatment of coronary arterial fistulae in children and adults]

The authors report their experience of endovascular treatment of coronary fistulae in 25 patients aged 2 to 77 years (median 29 years) who underwent 30 interventional catheterisation procedures. The origin of the fistulae was variable: left coronary (14 cases), right coronary (6 cases) and bilateral (5 cases) as were the sites of drainage: right atrium (5 cases), right ventricle (8 cases) pulmonary artery (7 cases) and bronchial artery (5 cases). Different materials were used: releasable balloons (9 cases), coils (17 cases), microparticles (5 cases) and Amplatzer occluder and plug (2 cases). The result, judged by occlusion or sub-occlusion of the given pedicle, was a success in 92% of cases. Total or sub-total occlusion of the fistula was obtained in 22 patients (88%); 2 patients had residual fistulae due to non-embolisation of the pedicle; in one patient, it was not possible to embolise the pedicle despite two attempts. A single serious complication, ventricular fibrillation during the catheterisation, was observed but without a sequel. Follow-up ranged from 6 to 176 months; 4 patients died of other causes, 3 were lost to follow-up; one coronaro-pulmonary fistula recurred but no other recurrence was observed in the other patients. The authors conclude that embolisation is the treatment of choice for coronary fistulae providing the cases are managed by teams trained in the use of different materials. The choice of material of embolisation should be adapted to the anatomical conditions which determine the success rate and the absence of complications.

Bosentan for the treatment of pulmonary arterial hypertension associated with congenital heart defects

BACKGROUND

Bosentan is an effective first-line therapy in New York Heart Association (NYHA) III patients with idiopathic pulmonary arterial hypertension (PAH). Pre-clinical data support the rationale for the potential benefit of bosentan in PAH associated with congenital heart disease (CHD).

MATERIALS AND METHODS

We performed a retrospective analysis of patients with PAH-associated CHD who were treated with bosentan on top of conventional therapy. Bosentan was started at 62.5 mg bid for 4 weeks, then titrated to 125 mg bid. New York Heart Association (NYHA) functional class, 6-min walking distance (6MWD), Borg dyspnoea index, arterial oxygen saturation and cardiopulmonary haemodynamic data (cardiac output, pulmonary blood flow and systemic and pulmonary vascular resistances) were collected at baseline and at follow up.

RESULTS

Twenty-seven patients (23 females, mean 35 +/- 15 years) with NYHA class III-IV PAH-associated CHD (not repaired in 23 cases) were treated with bosentan for a mean 18.3 +/- 9.9 months. Bosentan improved 6MWD from 298 +/- 92 m at baseline to 355 +/- 82 m at 3 months (P = 0.0002) and to 364 +/- 92 m (P = 0.0001) at the last follow up (mean 15.2 +/- 9.7 months). At the last follow up, 13 patients had improved (= 1 NYHA class) and 14 remained stable. A favourable effect was observed in pulmonary blood flow and pulmonary vascular resistance for the 11 available patients. No change in pulse oximetry or liver enzyme elevation was reported.

CONCLUSIONS

Bosentan improves exercise capacity, functional class and haemodynamics in most patients with PAH-associated CHD, without serious side-effects, suggesting bosentan may be an important treatment option for these patients.

[Large atrial septal defects in adults: results of attempted systematic percutaneous closure]

Percutaneous closure of ostium secundum atrial septal defects became routine practice from 1998 but remained limited by the size of their diameter at balloon calibration. In March 2004, after an experience of 551 patients, the maximum admissible diameter (40 mm), the biggest size available of the Amplatzer prosthesis, could often be exceeded. The essential anatomical condition was the presence of a circumferential edge--even minimal--except adjacent to the aorta where its absence was not a problem. From 31/03/04 to 31/12/05, 17 patients, 17 to 58 years of age, were included and underwent attempted percutaneous closure by the usual protocol. The insertion of the prosthesis was difficult in every case. It required the use of several techniques to orientate the prosthesis in a satisfactory plane without risking tearing part of the residual atrial septum. The attempt was successful in 16 of the 17 patients. The one failure occurred in a patient with complete absence of a posterior edge. The postoperative course was uncomplicated without residual shunt or displacement of the occluder in the follow-up studies. The authors conclude that very big atrial septal defects with diameters of over 40 mm may be closed percutaneously with the Amplatzer device with a reasonable chance of success. These attempts do not expose the patient to any particular risk and the results, in successful attempts, are comparable to those observed in smaller atrial septal defects.