Indications and limits of ultrasound-guided cytology in the management of nonpalpable thyroid nodules.

Although ultrasound (US)-guided fine needle aspiration biopsy (FNAB) is widely prescribed in nonpalpable thyroid nodules, the goal of this study was to define precisely the indications and limits of US-FNAB in a series of 450 nonpalpable nodules. Among 94 surgically controlled cases, 20 (8 infracentimetric and 12 centimetric or supracentimetric) carcinomas were diagnosed. The diagnosis of malignancy was successfully made by US-FNAB in 16 of 20 carcinomas, 3 were missed because of insufficient cytological material, and 1 was misdiagnosed. US-FNAB sensitivity and specificity were 94% and 63%, respectively. A logistic model indicated that nodule size (P < 0.6) was not associated with histological diagnosis, but that solid hypoechoic features were more likely to be malignant (P < 0.0003), with US sensitivity and specificity for malignancy of 80% and 70%, respectively. Logistic regression indicated that adequate cytological material significantly increased with nodule size (P < 0.0001). This result outlined the limits of US-FNAB in small nodules. Hence, indication of US-FNAB appears judicious in centimetric or supracentimetric nodules or in solid and hypoechoic ones. Such a management would allow the discovery of 15 of 20 carcinomas and would avoid 16% of unnecessary biopsies.

[Endocrine polyadenomatosis of 2a type (MEN 2a). Clinical and genetic study of a family]. / Polyadénomatose endocrinienne de type 2a (MEN 2a). Etude clinique et génétique d'une famille (GETC).

In a large kindred with multiple endocrine neoplasia type 2a (MEN 2a) (137 members, 5 generations), bilateral thyroid medullary carcinoma was found in all affected members. Pheochromocytoma was present in 59% of the cases, and was responsible at least for 4 out the 5 deaths related to MEN 2a. Hyperparathyroidism was less frequent (41%). Family screening leads to a reduction in age for diagnosis and to an improvement in the prevalence of complete healing after surgery. Linkage between HLA loci and a dominant gene for MEN 2a was investigated in this kindred. Lod scores for recombination fraction were all negative (-0.47 for a recombination fraction of 0.05). These results comfort the lack of linkage between MEN 2a and the HLA complex.

[Echography of thyroid nodules. The echography specialist facing the clinician's requirements]. / Echographie des nodules thyroïdiens. L'échographiste face aux exigences du clinicien.

The risk of malignancy in cases of unique non-functional thyroid nodules ranges from 5 to 20% and since definitive diagnosis can only be provided by the pathology examination, surgical removal could be planned in all cases. The clinician however also has the objective of proposing surgery to as few patients with benign nodules as possible and thus calls upon the echographist to help distinguish between malignant and benign nodules. Thus orders for echography carry an intrinsic request for diagnostic arguments, a precise analysis of the characteristics of the nodule and a description of possible multinodular dystrophy as well as an estimation of the probability of malignancy. The echographist's report must include a precise description of each thyroid lobe, the localization of the nodule, its size, contour, echostructure, echogenicity and calcifications. The cervical lymph node chains must also be explored. An analysis of the surrounding parenchyma can frequently confirm multinodular dystrophy. The size of the nodule is the determining factor in predicting malignancy. While for very small nodules, less than 1 cm in diameter, the malignant nature cannot be reasonably predicted, and inversely for very large nodules, invading an entire lobe, it is usually evident, for intermediate sized nodules, echography is a strategic diagnostic tool. No sign is pathognomonic but an association of arguments can favour malignancy: an unique isolated nodule, irregular contours, lymph node enlargement greater than 1 cm. Hypoechogenicity is another important characteristic with a positive predictive value of 50% to 63%. Overall, the sensitivity of echography is good at 75% with specificity of 61 to 83%.(ABSTRACT TRUNCATED AT 250 WORDS)

Subcutaneous insulin resistance syndrome. Effects of long-term aprotinin therapy.

The case of a young Type 1 diabetic patient with subcutaneous insulin resistance, causing recurrent ketoacidosis, is reported. Intramuscular and intravenous insulin administration remained effective. After failure of CSII, continuous intramuscular insulin infusion was used during 10 months followed by a combination of insulin and a protease inhibitor aprotinin, with good results. After 18 months' aprotinin therapy, subcutaneous insulin resistance disappeared. The subcutaneous insulin resistance syndrome and the role of aprotinin are discussed.

Hemostasis disorders in diabetes mellitus.

Hemostasis disorders are involved in diabetic micro and macroangiopathy. Platelet hyperactivity is related at least in part to an imbalance between thromboxane A2 and prostacyclin. Both hyper and hypoglycemia result in platelet activation.

[The provoked-hyperglycemia test. Follow-up after two years of 94 cases with doubtful results (author's transl)]. / Epreuves d'hyperglycémie provoquée douteuses. Leur évolution à moyen terme. A propos de 94 cas.

A retrospective study of 94 patients, who had had doubtful results in the oral provoked-hyperglycemia test, was made after an average period of 23 months. It was found that 26 patients were diabetic, 34 were normal and 34 were still doubtful. The factors which influence the evolution of these cases are the sex, a family history of diabetes (before 60 years of age), and the return to normal weight of obese patients.

[Paradoxical effects of iodine overload on thyroid function]. / Les effets "paradoxaux" d'une surcharge iodée sur la fonction thyroïdienne

Any chronic iodine overload resulting from long term ingestion of a medication or the administration of a non-resorbable contrast medium, may result in a goitre with or without hypothyroidism, and in particular in patients with a past history of thyroid disease. By contrast, the administration of iodine is no longer indicated in the treatment of enedmic goitres since the hypothesis of an iodine deficiency in the pathogenesis of such goitres may be excluded in most countries, and in particular western countries, and the risk of the development of thyrotoxicosis in such patients is not negligeable. It would thus be desirable that iodine no longer be used in the composition of medications when its presence is not indispensalbe and where, furthermore, it may contribute to developement of an increasingly disturbing iatrogenic complication.

[Value of the detection of antithyroid antibodies in thyroid pathology]. / Intérêt de la détection des anticorps antithyroïdiens en pathologie thyroïdienne.

Antithyroid microsomal hemagglutination antibody (MCHA) and antithyroglobulin hemagglutination antibody (TGHA) were measured in 629 patients with thyroid disease and 100 controls. Thyroid antibodies were present in 4% of control patients, only in women and at low titer. Thyroid antibodies prevalence was 97% in autoimmune thyroiditis (MCHA: 93%; TGHA: 53%), was 55% in Graves disease before treatment (MCHA: 46%; TGHA: 33%) and 90% in the first year following 131I therapy. Antibodies prevalence was 57% in myxoedema (MCHA: 52%; TGHA: 25%). In patients with iodine overload, antibodies prevalence was 29% in euthyroid patients, 25% in iodine-induced hyperthyroidism and 55% in iodine-induced hypothyroidism. Thyroid antibodies detection should be systematically performed in the routine evaluation of any thyroid disorder. Because of discrepancies between TGHA and MCHA positivity, their simultaneous detection should be performed.

[Anti-JKa specificity : a rare variety of auto-immune hemolytic anemia (report of a case associated with myxoedema (author's transl)]. / Une variété rare d'anémie hémolytique auto-immune : la spécificité anti-JKa.

The authors report the case of a patient with autoimmune hemolytic anemia, due to anti-KJa antibody, and associated with primary hypothyroidism. They discuss the possible relationship between these two conditions and emphasize the particular hematological pattern related to myxoedema.