Percutaneous Radiofrequency Ablation of Thyroid Carcinomas Ineligible for Surgery, in the Elderly.

Thirty to 50% of differentiated thyroid carcinomas include papillary thyroid microcarcinomas (mPTC). Most of these tumors remain clinically silent, have a bright prognosis and a disease-specific mortality <1%. Surgery has been recommended as first line-treatment by current guidelines, the standard treatment being lobectomy. However, surgery has some drawbacks, including potential recurrent laryngeal nerve paralysis, hypothyroidism, hypoparathyroidism, in -patient basis hospital stay, lifelong medication, scarring of the neck, and general anesthesia related risks. Moreover, elderly patients who present severe comorbidities, could be ineligible for surgery, and others may refuse invasive surgery. Another option supported by the American Thyroid Association is active surveillance. This option can be considered as unattractive and difficult to accept by European patients, as there is a 2-6% risk of disease progression. Percutaneous image-guided thermal ablation has been successfully applied in the treatment of liver and lung tumors in the 1990s and 2000s; and has recently been proposed as an alternative to surgery in patients presenting with thyroid diseases. This minimally invasive treatment has similar efficacy, fewer complications, better quality of life and cosmetic outcomes than surgery. We report herein two cases of radiofrequency ablation of mPTC and T2 PTC in elderly patients who were ineligible for surgery.

Fast Track Management of Primary Thyroid Lymphoma in the Very Elderly Patient.

A rapid growing cervical mass mobile while swallowing is the most common clinical presentation of severe thyroid malignancy. A 91-year-old female patient with a history of Hashimoto thyroiditis presented with clinical compressive neck symptoms. The patient had gastric Maltoma diagnosed that was surgically resected thirty years ago. A straightforward process was needed to reach full histological diagnosis and initiate prompt therapy. Ultrasound (US) showed a 67 mm hypoechoic left thyroid mass with reticulated pattern without signs of locoregional invasion. Percutaneous trans isthmic US-guided 18G core needle biopsy (CNB) disclosed diffuse large B cell lymphoma of the thyroid gland. FDG PET revealed two distinct thyroid and gastric foci (both SUVmax 39.1). Therapy was initiated rapidly to decrease clinical symptoms in this aggressive stage III primitive malignant thyroid lymphoma. The prognostic nomogram was calculated by using a seven-item scale, which disclosed a one-year overall survival rate of 52%. The patient underwent three R-CVP chemotherapy courses, then refused further treatment and died within five months. Real-time US-guided CNB approach led to rapid patient's management that was tailored to patient's characteristics. Transformation of Maltoma into diffuse large B cell lymphoma (DLBCL) into two body areas is deemed to be extremely rare.

SFE-AFCE-SFMN 2022 consensus on the management of thyroid nodules: Thermal ablation.

The SFE-AFCE-SFMN 2022 consensus deals with the management of thyroid nodules, a condition that is a frequent reason for consultation in endocrinology. In more than 90% of cases, patients are euthyroid, with benign non-progressive nodules that do not warrant specific treatment. The clinician's objective is to detect malignant thyroid nodules at risk of recurrence and death, toxic nodules responsible for hyperthyroidism or compressive nodules warranting treatment. The diagnosis and treatment of thyroid nodules requires close collaboration between endocrinologists, nuclear medicine physicians and surgeons, but also involves other specialists. Therefore, this consensus statement was established jointly by 3 societies: the French Society of Endocrinology (SFE), French Association of Endocrine Surgery (AFCE) and French Society of Nuclear Medicine (SFMN); the various working groups included experts from other specialties (pathologists, radiologists, pediatricians, biologists, etc.). This section deals with thermal ablation, which may constitute an alternative to thyroid surgery in selected patients.

High-intensity focused ultrasound (HIFU) therapy for benign thyroid nodules: a 3-year retrospective multicenter follow-up study.

BACKGROUND: Outcomes of high-intensity focused ultrasound (HIFU), as a non-surgical treatment option for benign symptomatic thyroid nodules, has mainly been based on single-center studies and short-term follow-up. Therefore, we assessed the safety, and long-term efficacy of HIFU in benign thyroid nodules among four centers with expertise in thyroid mini-invasive procedures. PATIENTS AND METHODS: Retrospective three year follow-up study in four European centers, treating solid benign thyroid nodules causing pressure symptoms and/or cosmetic concerns. Nodule volume reduction was assessed at 1, 3, 6, 12, 24, and 36 months post-treatment. Technical efficacy, defined as a volume reduction rate (VVR) >50% was evaluated at 6, 12, 24 and 36 months. Predictive factors of efficacy were assessed using logistic models. Complications and side effects were classified according to the Interventional Radiology Guidelines and changes in local symptoms were scored on a visual-analog scale. RESULTS: Sixty-five patients (mean age 51.1 ± 14.0 years; 86.2% women) with a single thyroid nodule and a mean baseline nodule volume of 9.8 ± 10.3 mL were treated with a mean energy of 7.1 ± 3.1 kJ (range: 2.0 to 15.5 kJ). Median nodule volume reduction was 31.5% (IQR: -38.6% to -23.1%) at 12 months and 31.9% (IQR: -36.4% to -16.1%) at 36 months. Technical efficacy was obtained in 17.2% of cases at 6 months, 17.8% at 12 months, 3.4% at 24 months, and 7.4% at 36 months. The number of treated pixels and the mean energy delivered were positively correlated to VRR at 1, 6 and 12 months. The risk of treatment failure decreased by 4.3% for each additional unit of energy delivered. The procedure duration was inversely correlated with treatment failure (OR 1.043, 95% CI: 1.011-1.083; p = 0.014). Improvement of cervical pressure symptoms or cosmetic complaints were observed in less than 15% of the cases at 12, 24 and 36 months. Horner's syndrome occurred in one case (1.5%) and minor complications, not requiring treatment, in three (4.6%) patients. No change in thyroid function was registered. CONCLUSIONS: HIFU carried a low risk of complications. A single treatment resulted in a 30-35% thyroid nodule volume decrease within one year, reduction that remained stable for 2 years. Outcomes varied significantly between centers with different HIFU expertise. Focus on improved HIFU technology, adequate training, and appropriate selection of patients is needed to achieve efficacy comparable to other thermal ablation procedures.

Safety and efficacy of thermal ablation (radiofrequency and laser): should we treat all types of thyroid nodules? †.

Background: Thermal ablation is a minimally invasive technique that is gradually acknowledged as an effective alternative to surgery to treat thyroid nodules. Two main techniques have been described: radiofrequency (RFA) and laser ablation. Objective: To evaluate the safety and efficacy of the two main techniques (RFA and laser ablation) for the treatment of benign thyroid nodules. Patients: This bicentric retrospective study included 166 consecutive patients, who received clinical, biological and ultrasound evaluations for thyroid nodules, from October 2013 to November 2017. Methods: One of the two techniques was proposed if a nodule was proven to be benign after fine needle aspiration cytology or micro-biopsy. Adverse events and outcomes (symptoms, nodule reduction) were assessed at 6 weeks and 6, 12, and 18 months after treatment. Results: One hundred and eighty-nine nodules (mean size 17.5 ± 16.9 mL, 86.1% palpable) were treated by RFA (n = 108 (57.1%)) or laser ablation (n = 81 (42.9%)) in 166 patients (80.1% women, mean age 51.7 years). Two cases of transient recurrent laryngeal nerve palsy, one hematoma, and two successfully drained abscesses (5/166 = 3%) were observed. Clinical symptoms improved significantly in the two groups (anterior cervical discomfort -83.6%, esthetic complaints -84.9% and dysphagia -86.4%). Nodule volume (mL) decreased significantly (baseline vs. 18 months) from 20.4 ± 18.6 to 5.8 ± 6.6 (-75%) in the RFA, and from 13.6 ± 13.3 to 3.4 ± 4.1 (-83.9%) in the laser ablation groups. Conclusions: Transient but potentially serious adverse events were reported in 3% of patients. A significant volumetric reduction was achieved with both techniques, regardless of nodule's characteristics, at 18 months.

Assessment of insulin sensitivity (S I) and glucose effectiveness (S G) from a standardized hyperglucidic breakfast test in type 2 diabetics exhibiting various levels of insulin resistance.

We investigated the measurement of insulin sensitivity (S I) with a standardized hyperglucidic breakfast (SHB) compared to minimal model analysis of an intravenous glucose tolerance test (S I-IVGTT) in 17 patients clinically referred as type 2 diabetics, not yet treated by insulin, and representing a wide range of body mass index and S I. To classify the patients, ten meal-tolerance test-based calculations of S I (MTT-S I) were compared to S I-IVGTT, and their reference values and distribution were measured on a separate sample of 200 control SHBs and 209 control IVGTTs. Eight MTT-SI indices exhibit significant correlations with S I-IVGTT: Mari's OGIS index, BIGTT-SI|0-30-120, BIGTT-SI|0-60-120, 1/G b I m, Caumo's oral minimal model (OMM), Sluiter's index "A" = 10(4)/(I p·G p), Matsuda's composite index given by the formula ISIcomp = 10(4)/(I b G b I m G m)(0.5), S I = 1/I b G b I m G m with r (2) ranging between 0,53 and 0,28. S I-IVGTT and S I-MTT exhibited in the lower range a very different (non-normal) pattern of distribution and thus the cutoff value for defining insulin resistance varied among indices. With such cutoffs, S I-MTT < 6.3 min(-1)/(µU/ml) 10(-4) with Caumo's OMM was the best predictor of insulin resistance defined as S I-IVGTT < 2 min(-1)/(µU/ml) 10(-4). Other indices, including OGIS and BIGTT, resulted in more misclassifications of patients. HOMA-IR and QUICKI were poor predictors. The formula [Formula: see text] satisfactorily predicts IVGTT-derived glucose effectiveness in type 2 diabetics. Thus, SHB appears suitable for the measurement of S I and S G in type 2 diabetics, and the OMM seems to provide the most accurate SHB-derived index in this population.

Long-term outcome and disability of diabetic patients hospitalized for diabetic foot ulcers: a 6.5-year follow-up study.

OBJECTIVE: The long-term outcome and functional status of subjects hospitalized for diabetic foot ulcers have been poorly studied and thus are the topics of this study. RESEARCH DESIGN AND METHODS: Ninety-four consecutive diabetic subjects hospitalized for diabetic foot ulcers between January 1998 and December 2000 were prospectively followed for mean +/- SD 79.5 +/- 13.3 months. We calculated rates of primary healing, new ulcers, amputations, mortality, and disability and evaluated the global therapeutic success (GTS) of foot care management as defined by the association of primary healing without recurrence or disability at the end of follow-up. RESULTS: Follow-up was successful in 89 of 94 subjects (63 men and 31 women; age 63.7 +/- 10.8 years). Of these, 69 (77.5%) experienced primary healing without major amputation, 39 (43.8%) underwent amputation (24 minor and 15 major), and 46 died (51.7%), including 23 from cardiovascular events. Forty-two of 69 patients who experienced primary healing (60.9%) had ulcer recurrence. At the end of the follow-up period, 25 patients (28.1%) were dependent and 40 subjects (44.9%) had achieved GTS. Multivariate analysis showed the role of age as an independent predictor of GTS (P < 0.05) and of impaired renal function/albuminuria as independent predictors of healing failure, first amputation, and mortality (P < 0.01). CONCLUSIONS: Despite a satisfactory initial healing rate, the global long-term outcome of patients hospitalized for diabetic foot ulcers was poor. Nephropathy appears to be an important predictor of long-term outcome. Further studies are needed to establish recognized criteria for therapeutic success going beyond just the evaluation of healing rate in the management of diabetic foot ulcers.

Oxidative mechanisms at rest and during exercise.

Carbohydrates (CHO) and lipids provide the amount of energy required for physical and chemical reactions inside the human body. The various constraints the body has to resolve explain the use of these two substrates, catabolized via distinct pathways to one common final reaction. In the classic model, three main organs/tissues for substrate fluxes (liver, adipose tissue and skeletal muscle) and one organ regulating main reactions by adaptation of hormonal secretions (endocrine pancreas) are described. From this point of view, the only interactions between CHO and lipid metabolisms are mediated by glycaemic changes via insulin/glucagon ratio (IGR). However, according to recent advances, this concept seems to have a limited validity as it does take into account neither the many other interactions between CHO and lipid metabolism that are likely to occur in addition to the coarse control by IGR, nor the long-term regulation of energy balance, whose description began with the discovery of leptin. Moreover, it does not include the effects of energy expenditure. Therefore, this review focuses on three topics: (i) describe interactions between CHO and lipid metabolism at the level of each tissue and organ implied, via hormonal signaling as well as direct action of nutrients, (ii) integrate fluxes of substrates and signals between those tissues at rest in a global view of the metabolism taking into account short-term and long-term regulating factors and (iii) describe separately, to avoid confusion or extrapolation, the short-term and long-term influence of exercise on these regulation loops.