[German guideline on undescended testis-what is relevant in daily routine?] / Praxisrelevantes aus der S2k-Leitlinie Hodenhochstand ­ Malsdescensus testis.

With an incidence of 0.7-3% in male infants, undescended testicles is one of the most common congenital anomalies. In the first 6 months of life, the testicles may spontaneously descend in up to 70% of individuals. If the testicle is not in a scrotal position afterwards, fertility can gradually be reduced and the risk of a testicular tumor increases. Therefore, the current German guideline for undescended testis recommends that therapy should be take place between 6 and 12 months of life. After extensive information on the advantages and disadvantages, hormone therapy with the aim of a descensus or in those with bilateral anomaly with the aim of improving the germ cell pool can be offered. After the first year of life, hormone therapy is obsolete. Otherwise, surgical intervention is the treatment of choice. In the case of gliding or deep inguinal testis via scrotal or inguinal access, in the case of nonpalpable and sonographically undetectable testis, laparoscopy is carried out for diagnosis and simultaneous therapy. In the first postoperative year, adequate follow-up should be done to detect a re-ascensus and/or insufficient growth. Regular self-examinations from the age of 15 serve for the early detection of a testicular tumor that occurs only very rarely (approximately 0.003%).

[Diagnostic management of primary megaureter : Voiding cystourethrography obligatory, scintigraphy useful?] / Diagnostisches Management des primären Megaureters : Miktionszysturethrographie obligat, Szintigraphie sinnvoll?

A primary, congenital megaureter means a dilatation of the ureter with a ureteric diameter ≥7 mm due to a structural or functional obstruction of the ureterovesical junction and represents the second most likely cause of neonatal hydronephrosis. Conservative management is the primary treatment option for many patients due to a high spontaneous remission rate of up to 85%. Concerning diagnostic management, meticulous and repeat postnatal evaluation by ultrasound is mandatory to identify patients who are at risk of renal deterioration. Routine voiding cystourethrography or contrast-enhanced voiding urosonography is currently recommended for all patients to detect vesicoureterorenal reflux and other concomitant pathologies. The relevance of the additional information provided by this examination must be critically questioned considering the lack of clinical consequences. Moreover, the question arises as to whether these examinations should be prolonged until clinical symptoms occur. Nevertheless, a subvesical obstruction should still be ruled out for male patients with a bilateral megaureter. The same critical discussion is necessary for the routine use of diuretic renography in patients with primary megaureter. In principal, this examination is used to determine the global as well as the split renal function and in addition is considered to offer an evaluation of the extent of obstruction. Similarly, the question arises of whether this examination should be mandatory for every child with a primary megaureter or whether the decision should be based on the extent of the upper urinary tract dilatation. The trend of diagnostic management should go towards individualized and risk-adapted diagnostic measures.

[Hypertension in polycystic ovary syndrome]. / L'hypertension artérielle au cours du syndrome des ovaires polykystiques.

UNLABELLED: Polycystic ovary syndrome (PCOS) is associated with multiple cardiovascular risk factors. The aims of this study are to investigate the prevalence of hypertension in a female population with PCOS and to correlate hypertension with her clinical and hormonal profile. MATERIALS AND METHODS: it is a transversal study of 79 PCOS patients with mean age of 25 +/- 7 years (range 13-44). PCOS diagnosis is made by Rotterdam consensus criteria's (2003). WHO definition of hypertension is used (BP 140/90 mmHg). Blood pressure is measured three times in each patient. Ovarian echography and biochemical assays (GnRH test, androgens, cholesterol, triglycerides, and oral glucose tolerance test) are made before the 5th day of the menstrual cycle. RESULTS: 12% of PCOS women have hypertension. Family history of hypertension is not a predictive factor of hypertension in our study. PCOS patients with hypertension are not significantly older than those without hypertension (28.4 +/- 6.5 vs. 25.2 +/- 7; p = 0.12). If compared to PCOS women without hypertension, those with hypertension have a significantly higher BMI (39.2 +/- 7 vs. 29.6; p = 0.0004). PCOS patients with and without hypertension do not differ significantly in their level of androgens and total cholesterol. Triglycerides level is higher in PCOS patients with hypertension (p = 0.06). In oral glucose tolerance test, areas under the curve of insulin and glucose are significantly higher in PCOS patients with hypertension (respectively p = 0.06 and 0.02). The area under the curve of LH during GnRH test is lower in PCOS patients with hypertension (p = 0.04).

[[18F]-FDG imaging in apparently isolated pleural lesions]. / L'imagerie nucléaire au [18F]-FDG dans les lésions pleurales en apparence isolées.

UNLABELLED: While a great deal of work has been performed concerning the impact of [18F]-FDG imaging in isolated lung lesion(s), there are still very few data about its role in case of isolated pleural lesions. The aim of this preliminary study was to shed some light on the utility of [18F]-FDG imaging, using PET or CDET detection, in this context. PATIENTS AND METHOD: Sixteen patients referred for apparently isolated pleural lesions were included in this study, since their 22 [18F]-FDG examinations were evaluable on bases of histology (9 cases), rapid disease progression (4 cases) or a follow-up period of more than 6 months (9 cases). Twelve [18F]-FDG examinations were performed with a dedicated PET machine (C-PET, Adac) and ten with a coincidence detection gamma camera (Irix, Picker). The precise clinical settings were the following: characterization of pleural masses or search for the unknown primary tumor in case of adenocarcinoma (6 cases), staging of a mesothelioma (5 cases), suspicion of recurrence and/or residual lesions (11 cases). RESULTS: The malignant pleural lesions took up [18F]-FDG in all cases. There was one false positive result due to an inflammatory lesion. False negative results for the detection of lymph node invasion occurred in three patients and were in relation with their infracentimetric size and the difficulty to distinguish on [18F]-FDG images mediastinal lymph nodes from widespread pleural and pulmonary extension of cancer. A change in patient management resulted from the [18F]-FDG examination in 4 patients (25%) and the course confirmed that the change was correct. Unknown lesions or active lesions wrongly considered residual that could have modified the management were discovered in 3 other patients. CONCLUSIONS: This study highlights the fact that [18F]-FDG imaging has an impact on the management of patients with solitary pleural lesions and can detect recurrences, in some cases even more accurately than invasive procedures with histology. In our limited experience, the lack of anatomical details of the PET images is a major drawback in this setting and we are convinced that PET-CT will substantially enhance the impact of [18F]-FDG imaging.

[Value of [18F]-fluorodeoxyglucose (FDG) positron emission tomography in digestive cancerology]. / Apport de la tomographie par émission de positons au [18F]-fluorodésoxyglucose (FDG) en cancérologie digestive.

COLORECTAL CANCERS: FDG-PET is a very effective tool in the follow-up of colorectal cancer for the early detection of recurrences, the search for other localisations in case of resectable lesions and for the evaluation of therapies. For the other digestive cancers, the data in the literature are less abundant and they do not yet have Marketing Authorization in France. OESOPHAGEAL CANCER: FDG-PET appears very promising for staging and detection of recurrences of oesophageal carcinomas. Pancreatic cancer Although the indication is difficult, FDG-PET appears superior to morphological techniques for the characterization and the locoregional staging of pancreatic tumours. BILARY AND GASTRIC CARCINOMAS: FDG-PET is promising but its role has to be confirmed in larger series for the detection of biliary and gastric carcinomas. OTHER DIGESTIVE TUMOURS: In cases of hepatocarcinoma, FDG-PET appears efficient only in cases of undifferentiated tumours, and in cases of malignant neuroendocrine digestive tumours, is useful in combination with somatostatin receptor imaging.

[(18)F]FDG in childhood lymphoma: clinical utility and impact on management.

Positron emission tomography (PET) with fluorine-18 fluorodeoxyglucose (FDG) is a very useful technique for the imaging of lymphomas in the adult population. It provides unique information about the behaviour of malignant cells and contributes to more accurate staging of the illness and better assessment of response to therapy. The purpose of this study was to evaluate the usefulness of FDG PET in childhood lymphoma compared with conventional imaging methods (CIMs) and clinical data. Between July 1998 and August 2001, 42 FDG PET examinations were performed using a dedicated PET system (27 examinations) or a hybrid coincidence PET system (15 examinations) for initial tumour staging ( n=7), restaging ( n=5) or assessment of response to therapy or residual masses ( n=30) in 27 children with Hodgkin's disease (HD) ( n=20) or non-Hodgkin's lymphoma (NHL) ( n=7). FDG PET results were compared with CIM findings and clinical data. Since 2000, a standardised questionnaire for evaluation of the clinical impact of FDG PET on both staging and therapy has been sent to the 16 referring physicians and 13 have replied. In all children, FDG PET was performed without any side-effects. FDG PET was found to be very sensitive (Se=12/12) for staging and restaging of the illness, showing more lesions than CIMs, with a 50% patient upstaging rate (6/12). It was very accurate for monitoring response to therapy and for characterisation of residual masses. False-positive results were observed in two NHL patients with thymic uptake and one false-negative result was obtained in a patient whose NHL relapsed 1 month after a negative FDG PET. The questionnaire emphasised the impact of FDG PET on clinical management, which was modified on the basis of the FDG PET results in 23% of patients. As previously demonstrated in the adult population, FDG PET appeared to be a very sensitive imaging technique for staging and restaging of lymphoma in children and was very useful for monitoring the response to therapy.

[Positron emission tomography (PET) with [18F]-FDG in bronchopulmonary cancer and its impact on medical decision at the time of diagnosis, staging, or recurrence evaluation]. / La tomographie par émission de positons (TEP) [18F]-FDG dans les cancers bronchopulmonaires et son impact sur la décision médicale lors du diagnostic, de la stadification ou de la recherche de récidive.

Clinical usefulness of [18F]-FDG imaging, performed by means of a dedicated or a "hybrid" PET machine, has been recognised in France since November 1998. Among the clinical indications, three major clinical settings of lung cancer have been included: characterisation, staging and detection of recurrences. After a brief presentation of the PET scintigraphic imaging modality, authors report on the experience of the nuclear medicine team of Hôspital Tenon and summarise the results in literature. For tumour characterisation, a recent meta-analysis obtained a 96% sensitivity, a 73% specificity, a 91% positive predictive value and a 90% negative predictive value, the performances being better for lesions greater than 1 cm. For staging, an increase greater than 15% both in sensitivity and specificity has been observed with dedicated or "hybrid" PET versus CT for N staging. Detection of distant metastases was also more accurate using [18F]-FDG. A similar increase was observed in the detection of recurrence, in accordance with our study; some authors described even better results. A better anatomical delineation of the lesions detected with FDG can be achieved by means of image fusion with CT; this technique is likely to develop as a routine tool in the near future. Finally, FDG imaging led to modification of patient's management in 37% of the cases according to a recent meta-analysis versus 53% of the cases in our retrospective survey concerning the first year of installation of a dedicated PET machine. This rate was equal with dedicated PET and with CDET. In 46% of the cases an inter-modality change occurred, and in 7% an intra-modality change consisting mainly in adaptation of the surgical procedure. As soon as the FDG examination became available, its clinical impact, in the French medical context, appeared to reach the highest values that were published internationally.

[(18F)-fluoro-2-deoxyglucose PET in imaging of gynecologic cancers]. / La TEP au [18F]-fluoro-2-désoxyglucose dans l'imagerie des cancers gynécologiques.

Although gynaecological cancers are not currently part of the clinical indications in the French registration for [18F]-fluoro-2-deoxyglucose (FDG), various studies indicate in this context a potential clinical benefit of imaging with this radiopharmaceutical and PET, a new imaging modality that can be performed either with a dedicated machine or with a "hybrid" gamma-camera (CDET). The potential indications of FDG-PET in mammary, ovarian or cervical cancers are reviewed according to the diagnostic phase: screening, tumour characterisation, staging, therapeutic follow-up and search for recurrence. By pooling the published results, the accuracy of FDG-PET could be estimated with a reasonable precision in various clinical settings: characterisation of a breast tumour (598/696 = 86%), lymph node invasion in breast cancer (525/602 = 87%), recurrence of breast cancer (114/127 = 90%), characterisation of adnexal masses (130/176 = 78%), recurrence of ovarian cancer (152/172 = 88%), lymph node invasion in cervical cancer (98/103 = 95%). Authors also present original data concerning their experience of recurrence detection with CDET in breast or ovarian cancers. In 44 patients suspicious of recurrence of breast cancer, FDG-CDET sensitivity was 94%, specificity 82% and accuracy 91%; in 18 patients suspicious of recurrence of ovarian cancer, specificity, sensitivity and accuracy were 100%. The impact of dedicated PET and CDET examinations performed by our team during year 2000, led, according to 63 forms returned to us, to a modification of stage in 48% of breast cancers, 36% of ovarian cancers, 43% of cervical cancers and above all induced a modification in patients' management in respectively 69%, 64% and 60% of cases, more than the average rate in cancer patients which was 50%. No significant difference was observed between clinical impact of dedicated PET and CDET examinations.

[18F]-FDG uptake in soft tissue dermatome prior to herpes zoster eruption: an unusual pitfall.

Authors report on a case of [18F]-fluorodeoxyglucose ([18F]-FDG) uptake in the soft tissue of a patient referred for [18F]-FDG coincidence detection emission tomography (CDET) in a search for recurrence of colorectal cancer. A herpes zoster eruption occurred in the same site within two days, but was spontaneously resolved. To the best of our knowledge this is the first description of a false positive [18F]-FDG result in relation to a viral infection of soft tissue. It shows that interpretation of subcutaneous foci has to be cautious in patients with or without a past history of herpes zoster even in pain-free areas and prior to skin eruption.

Evaluation of FDG uptake by renal malignancies (primary tumor or metastases) using a coincidence detection gamma camera.

UNLABELLED: The aim of this study was to evaluate the usefulness of FDG scanning using an ordinary gamma camera equipped with coincidence detection (CDET) for 2 renal cancer indications: characterization and staging of renal masses before nephrectomy and search for recurrence after nephrectomy. METHODS: Between September 1997 and June 1998, a whole-body scan and at least 1 tomoscintigram were obtained on 23 occasions in 22 patients (fasting for at least 6 h) using a Prism XP 2000 CDET gamma camera; scanning was begun 45 min after intravenous injection of 150-250 MBq FDG. RESULTS: Postoperative histologic evidence was obtained from 13 of 16 patients who underwent FDG using a CDET gamma camera before renal surgery; 4 renal masses did not accumulate FDG (3 true-negatives, 1 false-negative), whereas 9 renal tumors accumulated FDG (8 true-positives, 1 false-positive). In the other 3 patients, only 1 extrarenal site of FDG uptake was checked and confirmed on histologic examination: a bone metastasis from renal cell carcinoma in 2 cases and lymph node metastasis from a squamous cell carcinoma (3 true-positives). The primary local and regional staging of the malignant renal tumors was accurate in the 9 patients who underwent nephrectomy (8 true-negatives, 1 true-positive). The primary distant staging was positive in 1 case (focus in the chest corresponding to a probable true-positive on follow-up). In the 7 examinations performed because of suspected recurrence of renal cell carcinoma several months after nephrectomy, metastases were visualized by FDG in 4 patients, confirmed by biopsy in 2 patients, and confirmed by conventional imaging or follow-up (or both) in 2 patients. The other 3 patients had negative FDG scans, corresponding to probable true-negative results on follow-up. CONCLUSION: FDG using a CDET gamma camera can be used effectively for the staging and restaging of renal tumors and might be useful for characterization of the primary renal tumor in doubtful cases.

14. FDG CDET (2D Dual-Head Coincidence Gamma Camera) in the Primary Staging of Oesophageal Cancer. Histopathological Correlation.

Purpose: The aim of this study was to evaluate the role of FDG-CDET for the detection of primary oesophageal tumour, lymph node involvement and distant extension before surgery.Methods and patients: In patients fasting for 6h or more, 150-250 MBq of 18F-FDG were injected i.v. and 2D imaging (whole-body scan and at least a tomoscintigram) was started 45 min. later, using a PICKER gamma camera. We studied 14 patients (pts). All of them were operated on (mean time between FDG and surgery: 5.4 +/- 3.8 days) and staging results were correlated with post surgical histology.Results: The primary lesion took up FDG in all cases but one (FN in a 5 mm lesion). The primary NM staging of these 14 pts was negative with FDG-CDET in 7 cases (4 TN and 3 FN corresponding to an invasion of satellite lymph nodes in 2 cases and to a metastatic infracentimetric subdiaphragmatic lymph node in one case) and positive in 7 cases (7 TP corresponding to 10 foci), revealing in 4 cases a sub-diaphragmatic lymph node extension unknown prior to FDG-CDET. One pt referred for characterisation of an oesophageal lesion (failure of multiple biopsies) had an intense focus of FDG uptake in this area (TP confirmed by surgery). The overall sensitivity was 13/14 = 93% on a per patient basis and 21/25 = 84% on a per lesion basis. Specificity on a per lesion basis was 5/5 = 100%.Conclusion: These first results, obtained in an indication of FDG not frequently evaluated even with dedicated PET systems, seem very promising, the oesophageal neoplastic lesions appearing to take up FDG with a high intensity.

15. Sensitivity of FDG CDET (2D Dual-Head Coincidence Gamma Camera) for the Detection of Occult or Doubtful Recurrences of Colorectal Cancer. Histopathological Correlation.

Purpose: The aim of this study was to evaluate the efficacy of FDG-CDET for the detection of recurrences of colorectal cancer, in occult disease or in doubtful cases at conventional imaging (CI). In all the evaluated cases, the result of FDG-CDET was compared with post surgical histology both on patient and on site bases.Methods and patients: After fasting for 6h or more, 150-250 MBq of 18F-FDG were injected i.v. and 2D imaging (whole-body scan and at least a tomoscintigram) was started 45 min. later, using a PICKER CDET gamma camera. Among the 214 examinations (ex) performed for detection of recurrences of colorectal cancer between Jul 1997 and Feb 2000, we only considered the 58 cases with negative or questionable CI and a post surgical histologic proof.Results: Patients were referred in three different contexts:

32. Detection of Recurrence of Ovarian Cancer using

Purpose: The aim of this preliminary study was to evaluate the role of FDG-CDET in detection of recurrence of ovarian cancer.Methods and patients: After a fast of 6 hours, the patient (pt) was injected I. V. with 150-250 MBq of [F-18]-FDG and imaging (whole-body scan and at least a tomoscintigram) was started 45 min. later, using a PICKER Prism XP 2000 CDET gamma camera. Between July 1997 and December 1999, 40 patients were studied for ovarian carcinoma. To date, the results of 23 patients are evaluable with reference to histology after surgery or long-term follow-up. From these 23 patients, 18 pts were referred for suspected recurrence of ovarian carcinoma: occult recurrence (OR) defined by an increase in serum CA-125 levels with negative conventional imaging (13 pts) or equivocal aspect at conventional imaging (5 pts).Results: In 13 pts referred for suspicion of OR, FDG-CDET was true positive (TP) in 11 cases all confirmed by histology after surgery and was true negative (TN) in the remaining 2 cases as confirmed by spontaneous normalization of CA-125 levels and no events during a 20-month follow-up. In the 5 pts with equivocal aspect on CT, 4 were (TP) with recurrent foci at FDG-CDET in 1 case and 1 was (TN) corresponding to a leïomyoma on histology after surgery. In summary, the overall sensitivity and accuracy on a per patient basis were 18/18 for FDG-CDET while sensitivity and accuracy of conventional imaging was only 6/18.Conclusion: These preliminary results in a clinical setting, which is not frequently evaluated on CDET gamma cameras, seem very promising.

Comparison of bone scanning and CA 15-3 serum concentration in the follow-up of breast cancer.

The follow-up bone scans (BS) of 158 women with breast cancer and without known bone metastases were reviewed and compared with serum CA 15-3 concentration. Ninety-three BS were systematic (normal serum CA 15-3) and 3 corresponded to proven bone metastases. Sixty-five BS were motivated:-by isolated bone pain (20 BS. 1 corresponding to metastases),-by bone pain and signs of progression of the disease (11 BS. 7 corresponding to metastases: elevated serum CA 15-3 except in one case), by known visceral metastases (20 BS. 6 corresponding to metastases with elevated serum CA 15-3), by an isolated increase of serum CA 15-3 (7 BS. 4 corresponding to metastasis) by local recurrence (7 BS. 1 corresponding to metastasis). These results show that bone metastases were diagnosed in 6 patients whose serum CA 15-3 concentration was normal. We conclude that the existence of normal tumor markers is not sufficient to exclude the possibility of bone metastases.

CA 15-3 and bone scintigraphy in the follow-up of breast cancer.

By means of the retrospective study of the clinical records of 158 women followed for breast cancer, we aimed to evaluate the consequences of a non-systematic indication for bone scan (BS) based either on CA 15-3 levels alone or a combination of tumor marker levels and clinical criteria. With the first option, the negative predictive value was 95% and 82% of the BS would have been avoided. With the second option, the negative predictive value was 97% and 59% of the BS would have been avoided. Furthermore, the preliminary results of a longitudinal study showed that those patients with normal CA 15-3 levels and positive bone scans showed a subsequent rise in CA 15-3 levels which frequently became elevated with a average delay of 15 months. Omission of systematic bone scans in the follow-up of breast cancer patients is likely to lead to a delay in the diagnosis of bone metastasis in 3% to 5%, the consequences of which have to be examined carefully.