[Uretero-iliac artery fistula: endovascular treatment. Complications of prolonged use of double J endoprosthesis]. / Fistule urétéro-artérielle iliaque: traitement endovasculaire. Complication du maintien prolongé d'une endoprothèse double J.

The authors report a case of fistula between the external iliac artery and the left ureter, in a patient with a double J stent for several years to treat iatrogenic ureteric stenosis. The diagnosis was suggested by the patient's history and the presence of bright haematuria from the left ureteric meatus. Interventional radiology established the positive diagnosis and allowed treatment by placement of a covered prosthesis in the external iliac artery. This is the fourth published case of endovascular treatment of an iliac uretero-arterial fistula.

[Prolactinoma in man: clinical and histological characteristics]. / Le prolactinome de l'homme: caractères cliniques et histologiques.

Prolactinoma usually occurs a small intrasellar tumor in women or as a large tumor in men. To determine whether the predominance of macroprolactinomas in men is due to a delay in diagnosis as has been suggested, or whether there is a sex-related difference in growth rate we conducted a retrospective study in 45 men and 51 women with prolactinomas. Preoperative prolactin level (PRL) was 2,789 573 ng/ml and mean tumor size was 26 2 mm. Prolactin levels and tumor size were significantly higher in women (292 74 ng/ml and 10 1 mm; p<0.01). There was no correlation with age at diagnosis or duration of symptoms. Giant tumors were only observed in men (n=8). Frequency of resistance to bromocriptine (30% vs 5%, p<0.01) and invasive tumors (52% vs 27%, p<0.001) were significantly higher in men than in women. Likewise, proliferation rate was higher for the prolactinomas in men (Ki-67: 2.6 1.1% positive nuclei vs 0.4 0.2%; p=0.08; PCNA: 5.0 2.3% vs 3.7 1.1%). In conclusion, prolactinomas in men are more aggressive than in women. They grow rapidly, often invade the cavernous sinus and are resistant to bromocriptine; proliferation rates can be increased.

Mono- and plurihormonal thyrotropic pituitary adenomas: pathological, hormonal and clinical studies in 12 patients.

In a series of 12 patients (eight women and four men, aged between 20 and 62 years), operated on for a pituitary adenoma shown to be thyrotropic by immunocytochemistry, we performed a retrospective and comparative analysis of clinical and biological data, tumor studies including immunocytochemistry with double labeling, and proliferation marker (proliferative cell nuclear antigen (PCNA) and Ki-67) detection, electron microscopy and culture. Our study leads us to confirm that thyrotropic tumors are rare (12 of 1174 pituitary adenomas: 1%). The main points arising were that: (1) high or normal plasma TSH associated with an increase in plasma alpha-subunit and high thyroid hormone levels is the best criterion for diagnosis; (2) the failure of TSH to respond to TRH or Werner's test is not a reliable criterion for diagnosis; (3) thyrotropic adenomas may be 'silent', without clinical signs of hyperthyroidism and with only slight increase in TSH, tri-iodothyronine and thyroxine concentrations; (4) mitoses and nuclear atypies are frequently detected in large tumors, which are invasive in more than 50% of cases - the first analysis of two proliferation markers (PCNA and Ki-67) bears out the relative aggressiveness of thyrotropic adenomas; (5) thyrotropic adenomas are frequently plurihormonal. Immunocytochemical double labeling, complemented by in vitro study, showed that thyrotropic tumor cells sometimes can or sometimes cannot cosecrete TSH, GH or prolactin. The pathological identification of monohormonal and plurihormonal adenomas seems to be supported by clinical and biological differences.

[Analytical evaluation of third generation TSH assay. Application to the exploration of thyrotropin suppression in differentiated thyroid cancer]. / Evaluation analytique d'un dosage de TSH de troisième génération. Application à l'exploration du freinage thyréotrope des cancers thyroïdiens différenciés.

Intravenous TRH (200 micrograms Protiréline) injection was performed in 137 patients who had undergone thyroidectomy for differentiated thyroid carcinoma and treated by a suppressive thyroid therapy. Serum thyroid stimulating hormone (TSH) was measured before and 30 minutes after the injection. 143 tests were performed. The TSH method used was a chemiluminometric assay (Chiron Diagnostics). We study the analytical characteristics of the method. The limit of detection was 0.003 mUI/l. Interassay precision showed a functional sensitivity of 0.015 m UI/l with 20% interassay CV in agreement with the third generation criterion. There was a good correlation between TSH values at T0 and T30 minutes. In 143 tests, 40 (28%) showed a basal TSH value less than 0.003 mUI/l; delta TSH (TSH at T30-TSH at T0) was less than 0.015 mUI/l in about 68% of the cases and less than 0.031 mUI/l for the others. In 20% of the tests (29) TSH T0 were between 0.003 and 0.015 mUI/l and delta TSH less than 0.204 mUI/l. Finally the 74 remaining tests with a basal TSH value higher than the functional sensitivity of the method showed delta TSH less than 0.4 mUI/l if the TSH T0 was less than 0.05 mUI/l. The delta TSH remained less than 0.6 mUI/l if the TSH T0 was less than 0.1 mUI/l. Inversely, if TSH T0 was higher than 0.1 mUI/l delta TSH could be higher than 1.0 mUI/l. Third generation TSH assay allows us to abandon TRH test for the follow-up of thyroidectomized patients with suppressive thyroid hormonotherapy in so far as TSH assay is well established. We conclude that a basal TSH less than the functional sensitivity (0.015 mUI/l) can predict a TSH response to TRH stimulation test less than 0.2 mUI/l.

Influence of age on the clinical presentation of prolactinomas in male patients.

OBJECTIVE: Secreting pituitary adenomas are usually not considered a disease of older people. However, in male patients, prolactin-secreting pituitary tumours occur at a similar frequency throughout the entire life span, giving the opportunity to study in this gender the influence of age on the clinical presentation and response to treatment of these tumours. METHODS: We conducted a retrospective study including 9 male patients aged >/=60 (range 60-73) years and 10 aged

Isolated aldosterone synthase deficiency caused by simultaneous E198D and V386A mutations in the CYP11B2 gene.

Isolated deficiencies in aldosterone biosynthesis are caused by mutations in the CYP11B2 (aldosterone synthase) gene. Patients with this deficiency have impaired aldosterone synthesis, exhibit increased plasma renin activity, secrete increased amounts of the steroid precursors DOC, corticosterone, and 18OHDOC, and are subject to salt wasting and poor growth. Two forms are generally distinguished. The first, corticosterone methyloxidase type I (CMO I or type 1 deficiency), is characterized by no detectable aldosterone secretion, a low or normal secretion of the steroid 18OHB, and are always found to have mutations that completely inactivate the encoded CYP11B2 enzyme. The second form (CMO II or type 2 deficiency) may have low to normal levels of aldosterone, but at the expense of greatly increased secretion of its immediate precursor 18OHB. These patients usually have a CYP11B2 enzyme with some residual enzymatic activity, especially 11beta-hydroxylase activity. We have studied two twins with an isolated aldosterone synthase activity who have a clinical profile typical of the type 1 deficiency. Their CYP11B2 genes are homozygous for three sequence changes, R173K, E198D, and V386A. In transfection assays these substitutions individually have modest effects on the encoded enzyme, but when found together they result in an enzyme with a decreased 11beta-hydroxylase activity, a large decrease of 18-hydroxylase activity, and no detectable 18-oxidase activity. This residual activity is more typical of that observed in patients classified as having CMO II deficiency, rather than CMO I deficiency, where no activity is detectable. This disparity between the CYP11B2 enzyme with residual activity and a clinical phenotypic typical of the type 1 deficiency, suggests that phenotype genotype relationships are not yet fully understood.

[Papillary microcarcinoma of the thyroid. 179 cases reported since 1973]. / Le micro-carcinome papillaire du corps thyroïde. 179 cas observés depuis 1973.

OBJECTIVES: Defined as a tumor measuring < or = 1 cm, the prognosis and treatment of occult papillary thyroid carcinoma has been the topic of some controversy. The aim of this study was to report experience with a series of 179 cases observed since 1973. PATIENTS AND METHODS: Occult papillary thyroid carcinoma was discovered in 179 patients aged 12 to 81 years (151 women and 28 men) at cervicotomy prescribed for Graves' disease (n = 9), toxic adenoma (n = 16), isolated nodule (n = 71), multinodular goiter (n = 74) or cervical node enlargement (n = 9). The surgical procedures were lobo-isthmectomy (n = 79), subtotal thyroidectomy (n = 74), or total thyroidectomy (n = 26) with node dissection in case of enlargement. Thyroxin was prescribed in all cases and annual follow-up was programmed. Five patients were lost to follow-up. RESULTS: Two cervical recurrences were observed warranting reoperation. None of the patients died from cancer-related causes. CONCLUSION: Minute papillary carcinomas of the thyroid are frequently discovered, but prognosis is generally excellent. Systematic total thyroidectomy and node dissection are not warranted. Only those lesions with an extrathyroid extension, associated node enlargement or inaugural metastasis require wide resection. These results are in agreement with a critical analysis of data reported in the literature demonstrating the exceptional nature, and in half of the cases, cure of metastatic occult papillary thyroid carcinoma.

Sex-related difference in the growth of prolactinomas: a clinical and proliferation marker study.

Prolactinomas in women commonly present as small intrasellar tumors, but are usually much larger in men. This discrepancy has generally been attributed to differences in the delay before diagnosis. However, studies comparing clinical and pathological correlates of growth of these tumors in both sexes are lacking. We conducted a retrospective study comparing 45 men and 51 women bearing prolactinoma to determine whether the predominance of large tumors in men was due to a delay in diagnosis or, rather, to a fundamental sex-related difference in tumor growth. Basal PRL levels (mean +/- SEM, 2789 +/- 573 ng/mL) and mean tumor diameter (26 +/- 2 mm) were significantly higher in men than in women (292 +/- 74 ng/mL and 10 +/- 1 mm, respectively; P < 0.001), but were not correlated to the age at diagnosis or the duration of symptoms. Giant tumors (n = 8) occurred in males only. The frequencies of bromocriptine-resistant tumors (30 vs.5%; P < 0.01) and invasive macroadenomas (52 vs.27%; P < 0.001) were significantly greater in men than those in women. Lastly, macroprolactinomas in males exhibited higher indexes of proliferating cells by Ki-67 immunoreactivity (2.6 +/- 1.1% of positive nuclei) than did similar tumors in female patients (0.4 +/- 0.2%; P = 0.08). We conclude that the predominance of large prolactinomas in men is due to a high frequency of rapidly growing tumors, which are often invasive and frequently bromocriptine resistant.

[Thyroid nodules: assay of serum thyrotropin and cytopuncture versus scintigraphy as first-line tests. Prospective study with 150 cases]. / Nodules thyroïdiens: dosage d'hormone thyréotrope sérique et cytoponction versus scintigraphie comme examens de première intention. Etude prospective sur 150 observations.

OBJECTIVE: Fine-needle aspiration (FNA) is now considered as the first-line investigation for the diagnosis of thyroid nodules. We searched for a more accurate and cost-effective methodology as this technique fails to recognized hot nodules, frequent in certain countries. PATIENTS AND METHODS: A prospective study was conducted in 150 patients to compare two diagnostic procedures: scintigraphy first combined with FNA in case of cold nodules versus TSH measurement plus FNA when TSH measurement plus FNA when TSH was not depressed. The results were subjected to cost/benefit analysis. RESULTS: Cystic nodules were found in 28 cases (including 3 hyperfunctionning nodules, with 5 suspicious smears (1 carcinoma). FNA was non-diagnostic in 26 patients; 12 were operated on (1 carcinoma), 14 had further FNA (5 suspicious, 9 benign). Altogether 56 nodules were removed, for toxic adenoma (n = 5), for suspicious (n = 21) or malignant (n = 12) smear, or on personal (n = 18) demand; 16 carcinomas were found (2 medullary, 13 capillary, 1 follicular carcinomas). With scintigraphy first, the cost was 787 French francs (FF) per patient. With TSH measurement and FNA, the cost was 554 FF per patient. In both cases, the same number of carcinomas were removed, and all the hot nodules (11 including 5 toxic adenomas) were detected. CONCLUSION: Serum TSH measurement, with scintigraphy if TSH is low, and FNA in all the other cases, is accurate and more cost-effective than scintigraphy as a first-line investigation for the diagnosis of thyroid nodule.

[Treatment of differentiated thyroid cancers of nodular type]. / Traitement des cancers thyroïdiens différenciés à forme nodulaire.

Papillary and follicular carcinomas are the most frequent thyroid cancers. The choice of the treatment is dependent on the prognostic scoring systems. A good prognosis is linked to the small size of the nodule (especially) microcarcinoma) the age of the patient (less than 40), the lack of extra-thyroid (for papillary cancer) or extra capsular (for follicular carcinoma) extension. Total thyroidectomy decreases the number of recurrences but does not modify the mortality. The risk of laryngeal nerve palsy and hypoparathyroidism is not negligible. Lobo-isthmectomy thus can be used in the low risk tumors. Radioactive iodine administration is rational after total thyroidectomy but its efficacy is questioned. Thyroxine treatment is always prescribed. Taking into account the risk of osteopenia and cardiovascular disturbances induced by iatrogenic thyrotoxicosis, the desirable serum TSH level is debated.

Clinical utility of sex hormone-binding globulin measurement.

The high-affinity binding of the sex hormone-binding globulin (SHBG) for testosterone and to a lesser extent for estradiol influences the circulating levels of these sex steroid hormones, their biodisposal to target cells as well as their mutual balance. Although the regulation of SHBG is still not completely understood, in vitro studies performed with human hepatocarcinoma (Hep G2) cells have shown that estrogens and thyroxine stimulate SHBG secretion, by increasing the steady state of its mRNA concentrations. These observations are in good agreement with studies showing that SHBG levels increase during oral administration of estrogens as well as in patients with thyrotoxicosis. Interestingly, SHBG levels are normal in syndromes such as the abnormal transport of thyroid hormones and/or the syndrome of thyroid hormone resistance, which can be confused with thyrotoxicosis. By contrast, the effects of androgens are controversial. In many patients with hirsutism, SHBG concentrations are low and correlate negatively with both body mass index and fasting insulin levels. Because of the inhibitory effect of both insulin and insulin-like growth factor-1 on SHBG secretion by Hep G2 cells in vitro, it has been proposed that SHBG levels could be a marker of insulin resistance and/or hyperinsulinism in humans. Furthermore, an increased risk for either noninsulin-dependent diabetes and/or the overall mortality are associated with decreased SHBG levels in postmenopausal women. Finally, in men, SHBG levels are positively correlated with the concentration of high-density lipoprotein cholesterol. Therefore, the measurement of SHBG in clinical practice can be a useful diagnostic tool for: (1) correctly interpretating testosterone and estradiol serum concentrations; (2) investigating androgen-estrogen balance in gonadal and sexual dysfunctions; (3) assessing the peripheral effect of the hormones which regulate SHBG productions, and (4) evaluating insulin resistance and cardiovascular risk.

[Circulating antigliadin antibodies. Prevalence in a diabetic (type 1 or 2) and non diabetic adult population]. / Anticorps anti-gliadine circulants. Prévalence dans une population adulte diabétique (de type 1 ou 2) et non diabétique.

OBJECTIVES: The level of circulating antigliadin antibodies is an essential element in diabetic patients with signs of coeliac disease. Intolerance to gluten can disrupt glucose regulation leading to greater risk of hypoglycaemia. Search for antigliadin antibodies could be a routine test in diabetics. METHODS: Plasma gliadin antibodies were measured by immunoenzymatic assay in adult subjects: 80 type 1 diabetics, 80 type 2 diabetics, 80 non diabetics without auto-immune disease. RESULTS: IgA antibodies were present in 6 type 1 diabetics (7.5%), 8 type 2 diabetics (10%) and 6 non-diabetics (7.5%). Anti-reticulin and anti-endomysium antibodies were measured in type 1 diabetics with antigliadine antibodies. They were present only in one patient (Tunisian) who suffered from a coeliac disease. CONCLUSION: In France, the prevalence of coeliac disease is very low. Antigliadin antibodies measurement is justified only in patients with clinical and/or biological symptoms of coeliac disease.

Magnetic resonance imaging with superparamagnetic iron oxide particles to evaluate hepatic macrophage-monocytic phagocytosis after arterial devascularization in minipigs.

RATIONALE AND OBJECTIVES: We examined the effects of arterial ischemia on the phagocytic activity of the hepatic macrophage-monocytic phagocytic system (MMPS). METHODS: Six minipigs were studied before and 24 hr after complete arterial devascularization of the liver. Magnetic resonance (MR) imaging was performed at 1.5 T using superparamagnetic iron oxide (SPIO) particles (18 mumol Fe/kg body weight) as an MMPS-specific contrast agent. Hepatobiliary scintigraphy, measurements of serum liver enzymes, and histology also were obtained. RESULTS: On MR imaging, the postcontrast-to-precontrast ratios of the arterially devascularized livers were significantly higher than the corresponding baseline values (p < .01). The greatest difference (52%) between the baseline and the postoperative values was observed on gradient-echo (GE) images. Scintigraphy, laboratory analyses, and histology results indicate that the MR imaging findings were probably predominantly attributable to a reduction in phagocytic activity of the hepatic MMPS. CONCLUSION: SPIO particles have already proved useful for improving detection of liver neoplasms on MR imaging, but they also may provide a novel way of evaluating the function of the hepatic MMPS in liver diseases.

[Treatment of severe obesity by calibrated vertical gastroplasty. 55 cases]. / Traitement de l'obésité sévère par gastroplastie verticale calibrée. 55 observations.

OBJECTIVES: Evaluate short-term outcome of calibrated vertical gastroplasty in obese subjects. METHODS: Calibrated vertical gastroplasty was performed in 55 obese subjects (BMI 43 +/- 1; age range 20-59 year). There were no post-operative complications. All the subjects were followed for 6 months and thirty one for a year. RESULTS: Weight loss reached 28 kg at 6 months and 36 kg at 1 year with an improvement in functional manifestations, especially for dyspnoea and, in half of the subjects, for signs of depression. New or worsened psychiatric problems were observed in 4 subjects. Post-prandial vomiting persisted for 1 year in 28 patients. Dietary intake was lowered (946 +/- 61 kcal/day) as was protein intake (43 +/- 3 g/24 hr). Impaired glucose tolerance, raised serum insulin, triglyceride and androgen levels were corrected in patients with abnormal levels before surgery. Serum vitamin B1 declined. CONCLUSION: These favourable results in the weight curve, functional problems and metabolic data should not mask the disadvantages and potential risks involved. Long-term prospective studies are required to determine the precise indications for this technique.

[Pheochromocytoma in Von Hippel Lindau disease. 3 cases]. / Le phéochromocytome de la maladie de Von Hippel Lindau. 3 observations.

Presenting 3 personally examined cases, the authors underline the incidence and the characteristics of pheochromocytoma associated with Von Hippel Lindau disease. In conclusion, a systematic screening for Von Hippel Lindau disease-often unrecognized to day-must be done in every patient presenting with pheochromocytoma.

Androgen suppressive effect of GnRH agonist in ovarian hyperthecosis and virilizing tumours.

OBJECTIVE: Recent studies have suggested that androgen secretion by ovarian virilizing tumours may be gonadotrophin dependent. The aim of this study was to investigate the suppressive effect of GnRH agonist administration on androgen secretion in women with such tumours. DESIGN AND PATIENTS: A single i.m. injection of D-Trp-6-GnRH (GnRHa), 3.75 mg, was given to five unrelated patients referred for clinical symptoms of virilization with plasma testosterone (T) levels greater than 7 nmol/l but with normal dehydroepiandrosterone sulphate (DHEAS) levels. Diagnoses of adrenal tumour or a non-classical 21-hydroxylase deficiency were screened for by the dexamethasone suppression test, ACTH stimulation test and adrenal CT scanning, and were ruled out in all patients. The one premenopausal patient received cyproterone acetate in a dose of 50 mg twice daily for 3 weeks, starting 1 week before GnRHa administration. MEASUREMENT: Testosterone, androstenedione (A), DHEAS, 17-hydroxyprogesterone (OHP), LH and FSH plasma concentrations were measured by radioimmunoassay of blood samples taken before and 3 weeks after GnRHa. RESULTS: In each patient, GnRHa suppressed gonadotrophin levels and reduced T and A to the range for normal control women. With these results, and because accurate localization of an ovarian androgen secreting tumour could not be achieved by pelvic ultrasonography and CT scanning, exploratory laparotomy was undertaken. A Sertoli-Leydig cell tumour was found in the premenopausal patient, and granulosa cell tumour, hilus cell tumour and two hyperthecoses in the four post-menopausal patients. After bilateral ovariectomy and hysterectomy in the post-menopausal woman and after unilateral ovariectomy in the premenopausal women, androgen levels were normalized. CONCLUSIONS: In virilized women, the findings of increased serum testosterone with normal gonadotrophin levels and GnRHa suppression of gonadotrophins leading to normalization of testosterone levels, suggest that various ovarian androgen-secreting tumours, as well as hyperthecosis, are not autonomous but apparently depend upon continuous gonadotrophin stimulation.

Enhancement of liver hemangiomas on T1-weighted MR SE images by superparamagnetic iron oxide particles.

OBJECTIVE: Superparamagnetic iron oxide (SPIO) particles are phagocytosed by cells of the macrophage-monocytic phagocytic system. They are usually used in MRI as a negative contrast agent, because of their strong T2* effect, to improve detection of tumors in the liver and spleen. However, they also have a potent T1 relaxivity. In the current study, we describe this T1 effect in liver hemangiomas. MATERIALS AND METHODS: Twelve patients (nine women and three men, aged from 38 to 76 years) with liver hemangiomas were examined by means of MRI at 1.5 T before and after intravenous administration of SPIO particles at a dose of 15 mumol Fe/kg body wt. Signal intensity was measured from regions of interest. RESULTS: Whereas on postcontrast T2-weighted SE images the hemangiomas showed on average a signal drop of 20% (p = 0.011) and 49% (p = 0.001) (first and second echo, respectively), their signal increased by 106% (p = 0.001) on postcontrast T1-weighted SE images. CONCLUSION: The T1 effect (signal enhancement) we observed in liver hemangiomas after infusion of SPIO particles could prove to be a useful new diagnostic feature that would help characterize these common lesions and differentiate them from other liver tumors.

[Prevalence of antimitochondrial antibodies in women with Hashimoto's thyroiditis]. / Prévalence des anticorps anti-mitochondries chez les femmes atteintes de thyroïdite de Hashimoto.

OBJECTIVES: Thyroid antibodies are present in more than 15% of patients with primary biliary cirrhosis. Inversely, the prevalence of antimitochondrial antibodies in patients with thyroid antibodies is still unknown. The aim of the present study was to evaluate the prevalence of antimitochondrial antibodies in women positive for thyroid microsomal antibodies. METHODS: Anti-thyroid microsomal positive sera were collected from 351 selected female patients (age range 40-70 years) then stored at -20 degrees C from September 91 to September 92. Anti-mitochondrial auto-antibodies were determined in all sera with enzyme-linked sorbent assay (ELISA) using purified antigen. RESULTS: M2 antimitochondrial antibodies were found positive in 7 cases (2%). On immunoblots, the pattern of antimitochondrial reactivity visualized for the 7 sera was similar to pattern of classical primary biliary cirrhosis sera. Six of the 7 patients were asymptomatic and 4 had normal liver function tests. Liver biopsy was carried out in 2 patients and fulfilled diagnosis criteria for primary biliary cirrhosis. Six out of the 7 patients had Hashimoto's thyroiditis (2 biopsy proven, 4 clinical and biological diagnosis). CONCLUSION: Patients with Hashimoto's thyroiditis would be a population at high risk of primary biliary cirrhosis. It would be interesting to screen these patients in order to ascertain the signification of antimitochondrial antibody positivity, especially when there is no apparent liver disease.

Case report 801: Osteoid osteoma of the coccyx.

In summary, a typical osteoid osteoma in the coccyx in a 13-year-old boy has been presented-a unique location. The clinical, radiological, and pathological aspects of osteoma are summarized. The relationship of osteoid osteoma to osteoblastoma is stressed; it is also stressed that the occurrence of osteoid osteoma in the coccyx is most unusual.

[Management of the solitary thyroid nodule; clinical evaluation]. / Prise en charge du nodule thyroïdien isolé; évaluation clinique.

The merits of clinical assessment in the management of isolated thyroid nodules is discussed on the basis of the data found in the literature and of a personal prospective study of malignancy criteria. This shows that no clinical feature alone is deciding. However the increased prevalence of thyroid cancer in some etiological contexts and in relation with some symptoms should lead to increased caution when interpreting the data of fine needle aspiration and monitoring subjects who have not been operated.