Papillary Thyroid Carcinoma with Desmoid-Type Fibromatosis: Review of Published Cases.

Desmoid-type fibromatosis (DTF) is a very rare variant of papillary thyroid carcinoma (PTC). It is essentially a dual tumor with a component of classical PTC with malignant epithelial proliferation (BRAF-mutated) and another component of mesenchymal proliferation (CTNNB1-mutated). We conducted a literature review on PTC-DTF. In total, 31 articles were identified, that together reported on 54 patients. The mean age was 47 years, with a 2.2:1 female predominance. No ultrasound features were found to be helpful in differentiating PTC-DTF from other PTC variants. Of the 43 cases that reported histological details, 60% had locally infiltrative disease (T3b or T4). Around 48% had cervical lymph node metastases, but none had distant metastases. While PTC-DTF may be locally more aggressive than classic PTC, its overall behavior is similar and can include extrathyroidal extension and lymph node metastases, which may contain a stromal component and show extranodal invasion. The mainstay of treatment for PTC-DTF is surgery, and the DTF component is not expected to be sensitive to radioactive iodine. External radiotherapy, non-steroidal anti-inflammatory drugs, tyrosine kinase inhibitors and chemotherapy have also been used in selected cases. Due to the rarity of these tumors and the lack of specific treatment guidelines, management should be discussed in a multidisciplinary team.

[Basal insulin therapy in patients with type 2 diabetes]. / Insulinothérapie basale chez les patients diabétiques de type 2.

Insulin therapy, often initiated after hygiene and dietary measures and non-insulin antidiabetics, is part of the treatment of patients with type 2 diabetes. Fear of injections or hypoglycemia often delays its implementation. However, its introduction is recommended in cases of poorly balanced diabetes despite a well-controlled therapeutic escalation but also in cases of acute imbalance. Introduction of insulin therapy requires patient education and close monitoring by the healthcare team. Type of insulin and its titration reduce the incidence of hypoglycemia in patients at risk. The determination of the fasting glycemic target - relative to HbA1c - for the titration of insulin is important to define for an optimal benefit (prevention of secondary complications)/risk (hypoglycemia, weight gain) balance.

L'insulinothérapie, souvent mise en place après les mesures hygiéno-diététiques et les antidiabétiques non insuliniques, fait partie du traitement des patients diabétiques de type 2. La peur des injections ou des hypoglycémies retarde souvent sa mise en place. Cependant, son introduction est recommandée en cas de diabète mal équilibré malgré une escalade thérapeutique bien conduite mais aussi en cas de déséquilibre aigu. L'insulinothérapie implique un enseignement au patient et un suivi rapproché par l'équipe soignante. Le type d'insuline et sa titration progressive permettent de réduire l'incidence des hypoglycémies chez les patients à risque. La détermination de la cible glycémique pour la titration de l'insuline est importante à définir pour une balance bénéfice (prévention des complications secondaires)/risque (hypoglycémie, prise pondérale) optimale.

Denosumab for the Treatment of Hypercalcemia in a Patient With Parathyroid Carcinoma: A Case Report.

Background: Refractory hypercalcemia is one of the major complications of parathyroid carcinoma. Case report: An 84-year old female patient presented with an acute confusional state due to hypercalcemia. This led to the diagnosis of primary hyperparathyroidism for which she underwent surgery. The initial histological diagnosis was interpreted as atypical parathyroid adenoma; the resection was microscopically incomplete. One year later, the patient presented with elevated calcium levels up to 3.89 mmol/l. Recurrent severe hypercalcemia required multiple hospitalizations. Review of the histology slides revealed that the initially resected lesion was in fact a parathyroid carcinoma. Treatment with the calcimimetic drug cinacalcet was poorly tolerated. Repeated administration of zoledronic acid only had transient effects on calcium levels, and bisphosphonate treatment was ultimately discontinued because of chronic renal failure. The patient then received denosumab (60 or 120 mg) when needed (nine doses over twenty months), the last dose in November 2020, which led to a reduction and control of here calcium levels. Currently, at three years after initial surgery, calcium levels are stable between 2.7-2.8 mmol/l and the patient has not required hospitalization for hypercalcemia for 10 months. Discussion: In case of parathyroid carcinoma, en-bloc resection is the first treatment. Denosumab has proven its efficiency in treating hypercalcemia in malignancy. Several case reports studied denosumab in hypercalcemia due to parathyroid carcinoma, and the treatment were efficient to decrease levels of calcium when repeated as needed or monthly. We report another case of refractory hypercalcemia treated with several doses of denosumab in a patient with parathyroid carcinoma.

[Arterial hypotension: behind the scenes]. / Hypotension artérielle : l'envers du décor.

Arterial hypotension is a frequently encountered phenomenon in clinical practice. It is responsible for multiple consultations and/or hospitalizations, mostly in elderly people. It is associated with an increased morbidity and mortality. Arterial hypotension can be constitutional, part of a syndrome, orthostatic, or secondary (drug induced, hypovolemia). The diagnosis can be done by measuring the blood pressure in the supine position, sitting and standing position, and by 24h ambulatory blood pressure monitoring. The first line of treatment is non-drug therapies . The most frequently used medical treatments are midodrine, and fludrocortisone. However specific molecules as droxidopa, pyridostigmine, erythropoietin can also sometimes be indicated.

L'hypotension artérielle est une condition fréquente. Elle génère de nombreuses consultations et est responsable d'un nombre important d'hospitalisations, surtout chez les patients âgés. Elle est associée à une augmentation des risques de morbidité et de mortalité. L'hypotension artérielle peut être constitutionnelle, liée à un syndrome, orthostatique, ou le plus souvent secondaire (médicamenteuse, baisse de la volémie). Le diagnostic se fait par une mesure de la tension artérielle en position couchée/assise et debout, voire une mesure de la tension artérielle de 24 heures. Le traitement de première ligne est non pharmacologique. Le traitement médicamenteux comprend essentiellement la midodrine et la fludrocortisone. Certains traitements plus spécifiques, droxidopa, érythropoïétine, pyridostigmine peuvent avoir aussi leur place.