Les granulomatoses rénales (GR) sont des maladies rares dont la fréquence est estimée entre 0,5 à 1,3 % des ponctions biopsies rénales (PBR) réalisées. Les GR restent peu étudiées dans la littérature ...et les modalités thérapeutiques et évolutives sont mal connues.
Nous avons analysé 44 observations de GR identifiées sur l’ensemble des PBR réalisées entre 1984 et 2005 dans la région Rhône-Alpes.
Notre population était composée de 25 hommes et 19 femmes. L’âge moyen au diagnostic était de 56 ans. Le délai diagnostic moyen était de 11 mois. L’insuffisance rénale était sévère avec une clairance de la créatinine moyenne de 24
mL/min, associée à une protéinurie dans 77 % des cas (taux moyen de 0,9 g/24 heures), et à une hématurie microscopique et une leucocyturie aseptique chez respectivement 30 et 25 % des patients. La sarcoïdose était la principale étiologie, dans 25 % des cas (
n = 11), suivie par l’origine immunoallergique (9 %,
n = 4), la tuberculose (6,8 %,
n = 3), les hémopathies (6,8 %,
n = 3), l’infection par le virus de l’immunodéficience humaine (
n = 1) et le rejet chronique chez un transplanté rénal (
n = 1). La GR était qualifiée d’idiopathique dans 48 % des cas (
n = 21). La sévérité de l’atteinte rénale expliquait le recours fréquent à l’épuration extra rénale (34 %,
n = 15). Trois patients ont justifié une greffe rénale. L’évolution était cependant plutôt favorable : la fonction rénale s’est finalement améliorée dans 41 % (
n = 18) et stabilisée dans 34 % des cas (
n = 15).
La sarcoïdose, les causes médicamenteuses et infectieuses sont les causes les plus fréquentes de GR. L’enquête diagnostique est compliquée par l’absence de données histologiques pathognomoniques sur la PBR. La corticothérapie est le traitement de référence des GR sarcoïdosiques, immunoallergiques et idiopathiques. Autant que possible, le traitement est étiologique.
Granulomatous interstitial nephritis (GIN) are identified in 0.5 to 1,3% of all renal biopsies. Renal outcome and treatment modalities are not clearly established in the literature.
We retrospectively analyzed a case series of 44 GIN identified among all renal biopsies performed between 1984 and 2005 in the Rhône-Alpes area.
The study population included 25 men and 19 women with a mean age of 56 years, and mean diagnostic delay was 11 months. Renal function was severely impaired (mean creatinine clearance 24
mL/min). Proteinuria was observed in 77% (mean value 0,9 g/24
h) of the patients and associated with microscopic hematuria and leukocyturia in 30% and 25%, respectively. The most common diagnosis was sarcoidosis (25%,
n = 11), followed by drug-induced GIN (9%,
n = 4), tuberculosis (6,8%,
n=3), hemopathy-related paraneoplastic GIN (6,8%,
n = 3), HIV infection (
n = 1) and chronic renal allograft rejection (
n = 1). In other patients, no aetiology was found (48%,
n = 21). Severity of renal failure justified hemodialysis in 34% (
n = 15) of the patients. Three patients underwent renal transplantation. Nonetheless, renal outcome was generally favorable: renal function improved in 41% (
n = 18) and stabilized in 34% (
n = 15) of patients.
Sarcoidosis, drug-induced and infections represent the main causes of GIN. Histologic features are not specific enough to determine the aetiology. Corticosteroids is the gold standard in sarcoidosis, drug-induced, and idiopathic GIN. Treatment is etiologic in the other cases.
Les liens entre la pathologie granulomateuse et les cancers sont suspectés depuis de très nombreuses années mais sont longtemps restés incertains. Cette association a longtemps été considérée comme ...fortuite. Cette mise au point se propose de faire la synthèse de la littérature actualisée dans ce domaine.
Indépendamment des granulomatoses d’origine infectieuse, la pathologie granulomateuse chez le patient cancéreux peut s’envisager sous deux angles. Le premier aspect est représenté par les granulomatoses systémiques de type sarcoïdose survenant avant, pendant ou après le cancer. Cette éventualité est assez rare mais les dernières études confirment l’existence d’un lien privilégié entre les deux pathologies notamment pour les hémopathies malignes, les cancers du testicule, les cancers bronchopulmonaires, les mélanomes et les hépatocarcinomes. Le second aspect concerne les réactions sarcoïdosiques pouvant s’observer, soit au contact de la tumeur, soit plus volontiers dans les ganglions de drainage ou même à distance du tissu tumoral. L’existence d’une réaction sarcoïdosique semble être associée à un meilleur pronostic du cancer en particulier pour la maladie de Hodgkin et les adénocarcinomes de l’estomac ; le processus granulomateux pourrait ainsi jouer un rôle de barrière (suffisant ou insuffisant) à la diffusion métastatique. L’immunothérapie utilisée en cancérologie (interféron) peut reproduire de façon expérimentale de véritables granulomatoses sarcoïdosiques.
Des outils diagnostiques fiables non invasifs seraient utiles pour différencier les lésions tumorales des réactions sarcoïdosiques chez les patients cancéreux. Le TEP-scan au 18-fluorodeoxyglucose (18-FDG) ne permet pas à lui seul de répondre à ces attentes mais pourrait être intéressant couplé au TEP-scan au 3-(18)F-alpha-méthyltyrosine ((18)F-FMT). L’étude histologique reste encore aujourd’hui presque toujours nécessaire.
Relationships between granulomatosis and cancers have been suspected for a long time. Nevertheless, few evidence has been reported until recently. Here, we present a literature review about the association of granulomatosis and neoplasia.
Aside from granulomatosis due to infectious disease, granulomas can be observed in cancer patients, mainly in two situations. Patients may rarely present with typical sarcoidosis occurring before, during or after the diagnosis of cancer. Recent studies have documented such a relationship particularly with lymphomas, testicular and lung cancers, melanomas and hepatocarcinomas. Secondly granulomas may be found as a sarcoid reaction in the vicinity of the tumour itself or more frequently in regional lymph nodes. Sarcoid reaction, reported in Hodgkin's disease and gastric adenocarcinomas, may be associated with a better prognosis. Granulomatous reaction could play an important role in the host's defences against metastatic extension. Immunotherapy such as interferon has been reported to induce systemic sarcoidosis probably by reproducing some physiopathological mechanisms involved in sarcoidosis.
Clinicians need novel non invasive diagnostic methods to differentiate neoplasia from benign sarcoid reactions. The 18-fluorodeoxyglucose (18-FDG) PET-scan has failed in this indication but the adjunction of a 3-(18)F-alpha-methyltyrosine ((18)F-FMT) PET-scan could be useful. Biopsies is still necessary in most of cases.
Une cause rare d’amaigrissement Pasquet, F.; Karkowski, L.; Felten, D. ...
La revue de medecine interne,
09/2010, Letnik:
31, Številka:
9
Journal Article
La bléomycine est un cytotoxique utilisé dans le traitement de nombreux cancers. Ses effets secondaires cutanés sont variés. Certains sont rares, mais spécifiques de la bléomycine. Nous rapportons ...l’observation d’un patient de 40 ans présentant un érythème flagellé après administration de bléomycine pour une tumeur germinale testiculaire métastatique. Les caractéristiques cliniques, histologiques et évolutives sont décrites. Cette complication semble pouvoir survenir indépendamment de la dose reçue et des modalités d’administration. La pathogénie reste débattue.
Bleomycin is a cytotoxic agent used in the treatment of various neoplasias. Its cutaneous adverse effects are diverse. Some of them are rare but specific. We report the case of a 40-year-old man presenting with a non-seminomatous testicular germ cell tumour who developed a flagellate erythema related to a bleomycin administration. Clinical features, histopathology and disease course are presented. This side effect is apparently neither related to the dose nor to the mode of administration of bleomycin. The etiopathogenic mechanism remains unknown.
Une ostéolyse des doigts Karkowski, L.; Carassou, P.; Debourdeau, P. ...
La revue de medecine interne,
2008, 2008-1-00, Letnik:
29, Številka:
1
Journal Article
Integration of specialist palliative care (PC) into standard oncology care is recommended. This study investigated how integration at the Cantonal Hospital St. Gallen (KSSG) was manifested 10 years ...after initial accreditation as a European Society for Medical Oncology (ESMO) Designated Center (ESMO-DC) of Integrated Oncology and Palliative Care.
A chart review covering the years 2006-2009 and 2016 was carried out in patients with an incurable malignancy receiving PC. Visual graphic analysis was utilized to identify patterns of integration of PC into oncology based on the number and nature of medical consultations recorded for both specialties. A follow-up cohort collected 10 years later was analyzed and changes in patterns of integrating specialist PC into oncology were compared.
Three hundred and forty-five patients from 2006 to 2009 and 64 patients from 2016 were included into analyses. Four distinct patterns were identified using visual graphic analysis. The ‘specialist PC-led pattern’ (44.9%) and the ‘oncology-led pattern’ (20.3%) represent disciplines that took primary responsibility for managing patients, with occasional and limited involvement from other disciplines. Patients in the ‘concurrent integrated care pattern’ (18.3%) had medical consultations that frequently bounced between specialist PC and oncology. In the ‘segmented integrated care pattern’ (16.5%), patients had sequences of continuous consultations provided by one discipline before alternating to a stretch of consultations provided by the other specialty. In the 2016 follow-up, while the ‘oncology-led pattern’ occurred significantly less frequently relative to the ‘specialist PC-led pattern’ and the ‘segmented integrated care pattern’, the ‘concurrent integrated care pattern’ emerged more frequently when compared with the 2006-2009 follow-up.
The ‘specialist PC-led pattern’ was the most prominent pattern in this data. The 2016 follow-up showed that a growing number of patients received a collaborative pattern of care, indicating that integration of specialist PC into standard oncology can manifest as either segmented or concurrent care pathways. Our data suggest a closer, more dynamic and flexible collaboration between oncology and specialist PC early in the disease course of patients with advanced cancer and concurrent with active treatment.
•Specialist palliative care into oncology was evaluated in an ESMO Designated Center 10 years following accreditation.•In the 2016 follow-up, there was a significant increase of integrative procedures implemented in clinical practice.•Notwithstanding, 20% of patients with incurable cancer did not receive specialist palliative care with concurrent treatment of cancer.•There is a persisting need to overcome barriers to early palliative care in medical oncology.
Purpose
The aim of this study was to evaluate interobserver agreement (IOA) on target volume definition for pancreatic cancer (PACA) within the Radiosurgery and Stereotactic Radiotherapy Working ...Group of the German Society of Radiation Oncology (DEGRO) and to identify the influence of imaging modalities on the definition of the target volumes.
Methods
Two cases of locally advanced PACA and one local recurrence were selected from a large SBRT database. Delineation was based on either a planning 4D CT with or without (w/wo) IV contrast, w/wo PET/CT, and w/wo diagnostic MRI. Novel compared to other studies, a combination of four metrics was used to integrate several aspects of target volume segmentation: the Dice coefficient (DSC), the Hausdorff distance (HD), the probabilistic distance (PBD), and the volumetric similarity (VS).
Results
For all three GTVs, the median DSC was 0.75 (range 0.17–0.95), the median HD 15 (range 3.22–67.11) mm, the median PBD 0.33 (range 0.06–4.86), and the median VS was 0.88 (range 0.31–1). For ITVs and PTVs the results were similar. When comparing the imaging modalities for delineation, the best agreement for the GTV was achieved using PET/CT, and for the ITV and PTV using 4D PET/CT, in treatment position with abdominal compression.
Conclusion
Overall, there was good GTV agreement (DSC). Combined metrics appeared to allow a more valid detection of interobserver variation. For SBRT, either 4D PET/CT or 3D PET/CT in treatment position with abdominal compression leads to better agreement and should be considered as a very useful imaging modality for the definition of treatment volumes in pancreatic SBRT. Contouring does not appear to be the weakest link in the treatment planning chain of SBRT for PACA.
Une complication rare de la gastroscopie Pasquet, F.; Pavic, M.; Karkowski, L. ...
La revue de medecine interne,
10/2008, Letnik:
29, Številka:
10
Journal Article
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