Endosonography: New Developments in 2006

Recent progress of the data processing applied to ultrasound (US) examination made it possible to develop new software. The US workstation of the last generation thus incorporated a computer into their center that allowed a very precise treatment of the US image. This made it possible to work out new images like three-dimensional (3-D) US, the US of contrast-harmonic associated with the intravenous injection with product with contrast for US, and finally even more recently, elastography. These techniques, currently quite elaborate in percutaneous US, are to be adapted and evaluated with echoendoscopy (EUS)

EUS-Guided Biliary Drainage

The echoendoscopic biliary drainage is an option to treat obstructive jaundices when ERCP drainage fails. These procedures compose alternative methods to the side of surgery and percutaneous transhepatic biliary drainage, and it was only possible by the continuous development and improvement of echoendoscopes and accessories. The development of linear setorial array echoendoscopes in early 1990 brought a new approach to diagnostic and therapeutic dimenion on echoendoscopy capabilities, opening the possibility to perform punction over direct ultrasonographic view. Despite of the high success rate and low morbidity of biliary drainage obtained by ERCP, difficulty could be found at the presence of stent tumor ingrown, tumor gut compression, periampulary diverticula, and anatomic variation. The echoendoscopic technique starts performing punction and contrast of the left biliary tree. When performed from gastric wall, the access is made through hepatic segment III. From duodenum, direct common bile duct punction. Dilatation is required before stent introduction, and a plastic or metallic stent is introduced. This phrase should be replaced by: diathermic dilatation of the puncturing tract is required using a 6F cystostome. The technical success of hepaticogastrostomy is near 98%, and complications are present in 36%: pneumoperitoneum, choleperitoneum, infection, and stent disfunction. To prevent bile leakage, we have used the 2 stent techniques, the first stent introduced was a long uncovered metallic stent (8 or 10 cm), and inside this first stent a second fully covered stent of 6 cm was delivered to bridge the bile duct and the stomach. Choledochoduodenostomy overall success rate is 92% and described complications include, in frequency order, pneumoperitoneum and focal bile peritonitis, present in 19%. By the last 10 years, the technique was especially performed in reference centers, by ERCP experienced groups, and this seems to be a general guideline to safer procedure execution

HER2 and gastric cancer

Le cancer gastrique reste la deuxième cause de décès par cancer dans le monde. Si l’incidence du cancer de l’estomac est en baisse dans les pays occidentaux, celle des cancers de la jonction œso-gastrique (JOG) augmente et dans 65 % des cas, le diagnostic est porté à un stade avancé. Lors de l’essai randomisé de phase III ToGA évaluant le trastuzumab (anticorps humanisé anti-HER2) associé à une chimiothérapie par cisplatine et 5-FU versus la chimiothérapie seule, la survie globale était significativement améliorée dans le bras trastuzumab plus chimiothérapie comparé au bras chimiothérapie seule. Seront envisagées les différentes obligations à respecter pour caractériser les cancers de l’estomac et de la FOG surexprimant HER2 sur les biopsies endoscopiques (au moins 8), sur la tumeur opérée et la muqueuse environnante. Le statut HER2 sera évalué par immunohistochimie puis par hybridation in situ. Dans l’étude TOGA, HER2 était positif dans 33,2 % des cancers de la JOG et seulement dans 20,90 % des cancers gastriques. Sont ensuite abordées les indications du trastuzumab dans ces cancers gastriques de même que les chimiothérapies associées et les autres thérapies actuellement en évaluation.Adenoma of the stomach is still the second cause of cancer mortality worldwide. Although the incidence of gastric cancer is decreasing in western countries, the gastroesophageal junction (GEJ) cancer is rising in incidence, with a diagnosis made at an advanced stage in 65% of cases. The phase III ToGA randomized trial assessing trastuzumab (humanized antibody anti-HER2) associated to chemotherapy by cisplatine and 5-FU versus chemotherapy alone showed that the overall survival was significantly improved in the trastuzumab + chemotherapy arm compared to chemotherapy alone. Some recommendations should be respected regarding the characterization of gastric and GEJ cancer overexpressing HER2 on endoscopic biopsies (8 at least) on the operated tumour and the neighbouring mucosa. The HER2 status will be evaluated by immunohistochemistry and by in situ hybridization. In the TOGA study, HER2 was positive in 33.2 % of GEJ cancers and only 20.90% of gastric cancers. The indications of trastuzumab in gastric cancer as well as the associated chemotherapies and other therapies currently assessed are reported

Percutaneous ablation of hepatocellular carcinoma: update in 2010

Le carcinome hépatocellulaire (CHC) est l’une des tumeurs malignes les plus fréquentes dans le monde. Jusqu’à présent, le seul traitement considéré comme curatif est la chirurgie. Suivant les séries, une survie à 5 ans est alors possible pour 12 à 46 % des patients. L’injection percutanée d’alcool a été, au début des années 80, la première technique de traitement local du petit CHC de moins de 3-5 cm unique. Depuis, d’autres techniques percutanées sont apparues comme la thermoablation par radiofréquence. Le traitement par radiofréquence est aujourd’hui le meilleur traitement percutané d’un CHC sur cirrhose Child-Pugh A ou B unique de moins de 4 cmde diamètre ou multiple (n < 3, de moins de 3 cm). Ce traitement peut représenter une alternative à la chirurgie d’exérèse. En cas de contre-indications à la radiofréquence, l’injection intratumorale d’acide acétique ou d’alcool absolu peut être un traitement efficace.Hepatocellular carcinoma (HCC) is the most common primary liver malignancy worlwide. Surgical resection can be a curative treatment for HCC. However, this cancer is usually associated with liver cirrhosis or chronic hepatitis, so most patients with HCC are not candidates for surgical resection owing to poor hepatic reserve. Several minimally invasive techniques, such as percutaneous ethanol injection, percutaneous microwave coagulation, radiofrequency thermoablation (RFTA), interstitial laser photocoagulation and percutaneous acetic acid injection, have been used to treat HCC. Percutaneous ethanol injection have been the most widely performed local treatment for small HCCs. The prognosis of patients with HCCs less than or equal to 3 cm in diameter who are treated with percutaneous ethanol injection is comparable to that of patients who are treated with surgical resection. Recent reports have indicated that RFTA is very effective for local control of small HCCs. It appears RFTA might be an alternative to percutaneous ethanol injection and also to surgery

What is the best percutaneous treatment for hepatocellular carcinoma?

Le carcinome hépatocellulaire (CHC) est une des tumeurs malignes les plus fréquentes. Jusqu’à présent, le seul traitement considéré comme curatif est la chirurgie. Suivant les séries, une survie à 5 ans est alors possible pour 12 à 46 % des patients. L’injection percutanée d’alcool a été, au début des années 80, la première technique de traitement local du petit hépatocarcinome de moins de 3-5 cm unique. Depuis, d’autres techniques percutanées sont apparues comme la thermo-ablation par radiofréquence. Le traitement par radiofréquence est aujourd’hui le meilleur traitement percutané d’un hépatocarcinome sur cirrhose Pugh A ou B unique de moins de 4 cm de diamètre ou multiple (n < 3, de moins de 3 cm). Ce traitement peut représenter une alternative à la chirurgie d’exérèse. En cas de contreindications à la radiofréquence, l’injection intra-tumorale d’acide acétique ou d’alcool absolu reste un traitement efficace.Hepatocellular carcinoma (HCC) is the most common primary liver malignancy. Surgery resection can be a curative treatment for HCC. However, this cancer is usually associated with liver cirrhosis or chronic hepatitis, so most patients with HCC are not candidates for surgical resection owing to poor hepatic reserve. Several minimally invasive techniques, such as percutaneous ethanol injection, percutaneous microwave coagulation, radiofrequency thermoablation (RFTA), interstitial laser photocoagulation and percutaneous acetic acid injection, have been used to treat HCC and metastatic liver tumors. Percutaneous ethanol injection is the most widely performed local treatment for small HCCs. The prognosis of patients with HCCs less than or equal to 3 cm in diameter who are treated with percutaneous ethanol injection is comparable to that of patients who are treated with surgical resection. Recent reports have indicated that RFTA is very effective for local control of small HCCs. It appears RFTA might be an alternative to percutaneous ethanol injection and also to surgery

Echoendoscopic biliary drainage: which place in 2017?

Le drainage biliaire sous échoendoscopie représente une alternative au drainage percutané ou à la chirurgie lorsque la CPRE a échouée. Ces techniques ont été rendues possible par le développement depuis les années 1990 des écho-endoscopes électroniques linéaires permettant la réalisation des ponctions écho-guidées. Malgré un taux de réussite appréciable, la CPRE est mise en échec notamment en raison d’une obstruction duodénale ou d’une chirurgie préalable (gastrectomie, duodénopancréatectomie céphalique). Ce drainage des voies biliaires par échoendoscopie, repose sur la ponction « échoguidée » soit de la voie biliaire principale, soit du canal hépatique gauche (segment III). Techniquement, il s’agit de créer une anastomose bilio-digestive entre les voies biliaires intra-hépatiques gauches ou le cholédoque, et l’estomac ou le duodénum en utilisant généralement un cystostome de 6F pour créer l'anastomose bilio-digestive et d’une prothèse biliaire métallique le plus souvent pour maintenir ouverte cette anastomose. Le taux de réussite de l’hépatico-gastrostomie est 80 % à 100 % (moyenne 84 %) et un taux moyen de complication de 13 %, pour la cholédoco-duodénostomie de 75 % à 100 % (moyenne 90 %) et un taux de complication de 18 %. Depuis une dizaine d’années, ces techniques sont réalisées en routine dans des centres spécialisés en drainage biliaire complexe.Echoendoscopic biliary drainage is an option to treat obstructive jaundice when ERCP drainage fails. These procedures represent alternatives to surgery and percutaneous transhepatic biliary drainage and have been made possible through the continuous development and improvement of echoendoscopes and accessories. The development of linear sectorial array echoendoscopes in early 1990 brought a new approach to the diagnostic and therapeutic dimensions of echoendoscopy capabilities, opening the possibility to perform puncture over a direct ultrasonographic view. Despite the high success rate and low morbidity of biliary drainage obtained by ERCP, difficulty can arise with an ingrown stent tumor, tumor gut compression, periampullary diverticula and anatomic variation. The echoendoscopic technique requires puncture and contrast of the left biliary tree. When performed from the gastric wall, access is obtained through hepatic segment III. Direct common bile duct puncture is achieved from the duodenum. Diathermic dilation of the puncturing tract is performed using a 6F cystotome and a metallic stent. The technical success of hepaticogastrostomy is near 80 to 100% (mean 84%), and complications are present in 13% of cases. The most common complications include pneumoperitoneum, bilioperitoneum, infection and stent dysfunction. To prevent bile leakage, we used the two-stent techniques. The overall success rate for choledochoduodenostomy is 75 to 100% (mean 90%). The described complications include, in decreasing order of frequency: pneumoperitoneum and focal bile peritonitis, present in 18% of cases. Over the last 10 years, the technique has typically been performed in reference centers, by groups experienced with ERCP. This seems to be a general guideline for safer execution of the procedure

Characterization of the axon initial segment (AIS) of motor neurons and identification of a para-AIS and a juxtapara-AIS, organized by protein 4.1B

<p>Abstract</p> <p>Background</p> <p>The axon initial segment (AIS) plays a crucial role: it is the site where neurons initiate their electrical outputs. Its composition in terms of voltage-gated sodium (Nav) and voltage-gated potassium (Kv) channels, as well as its length and localization determine the neuron's spiking properties. Some neurons are able to modulate their AIS length or distance from the soma in order to adapt their excitability properties to their activity level. It is therefore crucial to characterize all these parameters and determine where the myelin sheath begins in order to assess a neuron's excitability properties and ability to display such plasticity mechanisms. If the myelin sheath starts immediately after the AIS, another question then arises as to how would the axon be organized at its first myelin attachment site; since AISs are different from nodes of Ranvier, would this particular axonal region resemble a hemi-node of Ranvier?</p> <p>Results</p> <p>We have characterized the AIS of mouse somatic motor neurons. In addition to constant determinants of excitability properties, we found heterogeneities, in terms of AIS localization and Nav composition. We also identified in all α motor neurons a hemi-node-type organization, with a contactin-associated protein (Caspr)⁺paranode-type, as well as a Caspr2⁺and Kv1⁺juxtaparanode-type compartment, referred to as a para-AIS and a juxtapara (JXP)-AIS, adjacent to the AIS, where the myelin sheath begins. We found that Kv1 channels appear in the AIS, para-AIS and JXP-AIS concomitantly with myelination and are progressively excluded from the para-AIS. Their expression in the AIS and JXP-AIS is independent from transient axonal glycoprotein-1 (TAG-1)/Caspr2, in contrast to juxtaparanodes, and independent from PSD-93. Data from mice lacking the cytoskeletal linker protein 4.1B show that this protein is necessary to form the Caspr⁺para-AIS barrier, ensuring the compartmentalization of Kv1 channels and the segregation of the AIS, para-AIS and JXP-AIS.</p> <p>Conclusions</p> <p>α Motor neurons have heterogeneous AISs, which underlie different spiking properties. However, they all have a para-AIS and a JXP-AIS contiguous to their AIS, where the myelin sheath begins, which might limit some AIS plasticity. Protein 4.1B plays a key role in ensuring the proper molecular compartmentalization of this hemi-node-type region.</p

Neoadjuvant Docetaxel-Based Chemoradiation for Resectable Adenocarcinoma of the Pancreas

International audienceTo assess the safety and efficacy of a new neoadjuvant chemoradiation (CRT) docetaxel-based regimen in patients with resectable adenocarcinoma of the pancreatic head or body