[Diagnostic approach and therapeutic management of hyperthyroidism]. / Démarche diagnostique et prise en charge thérapeutique de l'hyperthyroïdie.

Hyperthyroidism is a frequent clinical situation that can be expressed by various signs and it is generally easy to diagnose. This review proposes to explain the diagnostic approach that affects therapeutic management by separating diseases with homogeneous and nodular thyroid.

The value of 18F-FDG positron emission tomography to differentiate benign from malignant intraductal papillary mucinous neoplasms: A prospective multicenter study.

OBJECTIVE: To assess the value of 18F-FDG PET/CT in differentiating between benign and malignant intraductal papillary mucinous neoplasms (IPMN) of the pancreas. SUMMARY BACKGROUND DATA: Malignant or high-risk IPMN require surgical resection but surgery should be avoided in patients with IPMN carrying a low risk of malignancy. 18F-FDG PET has been studied mostly in small, single center, retrospective series. METHODS: Prospective, non-comparative, multicenter French study. The primary endpoint was the specificity of PET/CT for identifying malignant IPMN (in situ or invasive carcinoma). Final diagnosis was obtained from pathological examination of the resected specimen. RESULTS: Among 120 patients analyzed, 99 had confirmed IPMN, including 24 with malignant lesions, namely 9 with carcinoma in situ and 15 with invasive carcinoma. The 18F-FDG PET/CT was positive in 44 and 31 patients in the overall and IPMN populations respectively. In the 99 IPMN patients, PET/CT showed 13 true positive, 18 false positive, 57 true negative and 11 false negative results. The sensitivity, specificity, negative predictive value (NPV) and positive predictive value (PPV) for the diagnosis of malignancy were 54.2%, 76.0%, 83.8% and 41.9% respectively, versus 64.9%, 75.9%, 82.9% and 54.5% in the overall population. We could not identify a cut-off value for SUVmax to distinguish benign from malignant lesions. Conventional imaging included computed tomography, magnetic resonance cholangiopancreatography and endoscopic ultrasound. In IPMN patients who underwent the 3 techniques, sensitivity, specificity, NPV and PPV were 66.7%, 84.4%, 84.4% and 66.7% respectively. CONCLUSIONS: In this study, 18F-FDG PET/CT did not perform better than conventional imaging to differentiate malignant from benign IPMN.

(18)F-FDG uptake at initial staging of the adrenocortical cancers: a diagnostic tool but not of prognostic value.

BACKGROUND: Adrenocortical carcinoma (ACC) is a rare cancer for which little level evidence exists to guide management. (18)F-FDG PET ((18)F-fluorodeoxyglucose positron emission tomography) is an increasingly used diagnostic tool in patients with suspicious or indeterminate adrenal tumors. In some other solid tumors, (18)F-FDG PET may offer prognostic information that can guide optimal patient treatment. The aim of the present study was to evaluate whether preoperative (18)F-FDG PET based on SUVs assessments has a prognostic value in ACC patients. METHODS: A retrospective analysis was performed in patients who underwent (18)F-FDG PET/CT for the evaluation of ACC. Inclusion criteria were an unequivocal diagnosis of ACC; all data from primary diagnosis available; (18)F-FDG PET/CT performed prior to surgery or other treatment of the primary tumor; a minimum of 6-months follow-up for surviving patients. All (18)F-FDG PET/CT procedures were reinterpreted in a blind fashion. RESULTS: Thirty-seven patients (23 without metastasis [M0], 14 with metastasis [M1]) fulfilled the study criteria. Median uptake values were tumor standardized uptake values (SUV)(max) = 11 (range: 3-56) and a tumor/liver SUV(max) ratio = 4.2 (range: 1.3-15). Median follow-up was 20 months. Although classic risk factors (tumoral stage, Weiss score) were associated with poor outcome, there was no correlation between primary tumor FDG uptake with overall survival (OS) and disease free survival (DFS) in M0 patients and with overall survival in M1 patients. (18)F-FDG uptake correlated inconsistently with sinister histological features, such as atypical mitoses or necrosis. CONCLUSIONS: At initial staging, primary tumor FDG uptake in ACC patients does not correlate with OS and DFS at 2 years. Patient prognosis and treatment strategy should not be based on uptake values.

Role and limitations of 18F-FDG positron emission tomography (PET) in the management of patients with pancreatic lesions.

The 18-fluorine-18-fluoro-2-deoxyglucose Positron Emission Tomography coupled with computed tomography is a non invasive exploration. Several studies have shown that PET-CT has superior efficacy over conventional imaging techniques in distinguishing a benign pancreatic tumor from a malignant one. It contributes to the diagnosis of cancer in patients with a doubtful mass, much more in case of chronic pancreatitis. PET-CT is also an important help for the diagnosis of cystic tumors of the pancreas; the results can affect the management strategy. It is interesting for the endocrine tumors, particularly since the emergence of new markers. The aim of this paper is to summarize the role and limitations of 18-F-FDG PET-CT in the management of patients with pancreatic lesions (adenocarcinoma, cystic tumors, endocrine tumors, etc…) concerning the malignancy diagnosis, the detection of metastases, the monitoring after non surgical treatments and to evaluate interpretation difficulties, particularly in case of diabetes or chronic pancreatitis.

Preoperative localization of parathyroid lesions. Value of 99mTc-MIBI tomography and factors influencing detection.

UNLABELLED: The AIM of our study was to assess retrospectively the value of (99m)Tc-MIBI SPECT in the localization of parathyroid lesions in primary hyperparathyroidism and to determine the impact of PTH level, age, sex, characteristics of the lesions and thyroid nodules on the sensitivity of imaging. PATIENTS, METHODS: Fifty nine patients who were cured after the resection of 60 lesions (50 adenomas, 9 hyperplasias and 1 carcinoma, 9 of them in ectopy) were selected. (99m)TcO(4)(-), early and late (99m)Tc-MIBI planar images (n = 59), (99m)Tc-MIBI SPECT (n = 58) and ultrasound (n = 50) performed preoperatively were analyzed. The imaging results were compared to surgical and histological findings and correlated to different factors suspected of influencing the imaging's sensitivity. RESULTS: Sensitivity of double phase (99m)Tc-MIBI/(99m)TcO(4)(-) scintigraphy was higher than that of early or late scintigraphy alone. SPECT increased the sensitivity of scintigraphy from 85% to 92% and was useful to confirm doubtful foci and to localize ectopic lesions. Ultrasound (US) had the lowest sensitivity (56%) and the highest rate of false-positive results (n = 10), but identified 2 adenomas which were not detected by scintigraphy. Combining all imaging modalities, sensitivity reached 96%. Better sensitivities were observed when age <69 years, preoperative PTH level > or =155 pg/ml, weight of the gland > or =0.80 g and in the absence of thyroid nodules. US was more influenced by these factors than scintigraphy. CONCLUSION: Combination of US, double-phase (99m)Tc-MIBI/(99m)TcO(4)(-) planar scintigraphy and SPECT is the most accurate method for the detection of parathyroid lesions and should be performed before minimally invasive surgery, especially when PTH level is low, in older patients and in cases of multinodular goiter.

[Interest of selective lymphadenectomy in patients with vulvar cancer]. / Intérêt de la technique de lymphadénectomie sélective dans les cancers de vulve.

Vulvar cancer represents approximately 4% of all gynecologic malignancies and the most important prognosis factor in this cancer is the status of the regional lymph nodes. The radical inguinal lymphadenectomy, associated or not with radiotherapy, is accompanied by high morbidity, which can affect 50% of the patients. The sentinel node detection appears now to be feasible in patients with vulvar carcinoma, in order to reduce the morbidity of inguinal lymphadenectomy. But contrary to breast cancer, the learning curve is not easy to obtain because of the low number of cases. That is why we have described the procedure of selective lymphadenectomy. The aim of this technique is to remove the blue and/or marked inguinal lymph node and any other palpable lymph node, without a real radical inguinal lymphadenectomy. Thus, since November 2003, 4 procedures have been performed in total. With the lymphoscintigraphy, we identified 17 marked lymph node and we finally obtained 28 lymph nodes after surgery, with only one metastatic lymph node. There was no complication after our procedure. Selective lymphadenectomy appears to be a new procedure which may reduce the morbidity of usual inguinal lymphadenectomy.