Radiodiagnóstico y Medicina Nuclear: caminos encontrados / Radiology's and nuclear medicine's paths converge

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[From incidentaloma to secondary discovery]. / De l'incidentalome à la découverte secondaire.

The term incidentaloma, created in 1982, has spread throughout medical literature. However, there does not seem to be a precise definition to describe what an incidentaloma is. In the initial uses, the word incidentaloma systematically designated a mass that was detected during an imaging examination prescribed for diagnostic purposes unrelated to the reason for carrying out the examination. Naming this mass "incidentaloma" did not give any precision on its nature as it can be located in many anatomical zones, secreting or not, benign or malignant, etc. Today, the term "incidentaloma" carries a much broader dimension which seems to cover the notion of incidental discovery, whether radiological, biological or genetic. The evolution of the term "incidentaloma" demonstrates its heuristic nature. It is a sign of a change in modern medicine which hesitates between a patient clinic and a data clinic. Fortuitous discoveries are a phenomenon known and anticipated by radiologists. Thus, these discoveries are no longer fortuitous, or even unexpected, but secondary to the use of health technology.

TITLE: De l'incidentalome à la découverte secondaire. ABSTRACT: Le terme incidentalome, créé en 1982, s'est, depuis, diffusé dans la littérature médicale. Il ne semble cependant pas exister de définition précise pour décrire ce qu'est un incidentalome. Dans les usages initiaux, l'incidentalome désignait une masse détectée à l'occasion d'un examen d'imagerie prescrit à visée diagnostique sans qu'un lien ne soit déterminé avec le motif de réalisation de l'examen. La qualification d'« incidentalome ¼ de cette masse n'apportait aucune précision sur sa nature, celle-ci pouvant être située dans de nombreuses zones anatomiques, être sécrétante ou non, être bénigne ou maligne… Aujourd'hui, le terme d'incidentalome porte une dimension beaucoup plus large, semblant recouvrir la notion de découverte fortuite, qu'elle soit radiologique, biologique ou génétique. Cet usage évolutif du terme démontre son caractère heuristique. Il est le signe d'une modification de la médecine moderne qui hésite entre une clinique des patients et une clinique des données. Les découvertes fortuites sont un phénomène connu et anticipé par les radiologues. Ces découvertes ne sont donc plus fortuites, ni même inattendues, mais bien secondaires à l'usage de la technologie en santé.

The Birth, Death, and Renaissance (?) of Dissection: A Critique of Anatomy Teaching With-or Without-the Human Body.

A riveting debate regarding the fate of dissection, the classical method of anatomy, is sweeping through medical academia, as imaging tools gain a greater foothold in anatomy teaching programs. This Perspective does not aim to grapple with the question of "how should anatomy be taught" but rather to explain why the transformation of anatomical education is taking place by situating these developments in the broader philosophical context of modern medicine, offered by Michel Foucault's The Birth of the Clinic: An Archaeology of Medical Perception. Emphasizing the body's crucial role in the epistemological change in medical practice in the early 19th century, Foucault coined the term "medical gaze" to denote the doctor's observation of the patient's body in search of signs of disease. Within this new systematic perception of disease, which brought about the anatomo-clinical method, the clinical gaze thus embraced the study of the body via dissection. The author contends that the introduction of medical imaging into the diagnostic process has resulted in a shift in the focus of the clinical gaze from the body to its medical image and that this process is mirrored in anatomy by its discarding of the cadaver. Given the fundamental differences between the phenomenology of the body and its medical image, the author suggests that when using medical images in medical schools and teaching hospitals, one teaches, at the very least, a new kind of anatomy. Foucault's analysis of the painting The Treachery of Images by Réne Magritte lends some support to the ideas presented here.

[Giant cell arteritis: Role of color-duplex ultrasound]. / Artérite gigantocellulaire : apport de l'écho-doppler.

Giant cell arteritis is the most common primary vasculitis of large-vessel occurring in subjects over 50 years of age. Many imaging techniques has been evaluated to improve the diagnosis of giant cell arteritis. Among these imaging techniques, ultrasound has shown good performances to detect inflammatory involvement of the temporal arteries as well as branches of the aorta. Several publications and recent EULAR recommendations have emhasized the place of this tool in the diagnosis of giant cell arteritis.

Imaging the unimaginable: Medical imaging in the realm of photography.

There is an almost innate urge in human beings to represent reality in a visual form. From rock art in the Paleolithic to images of galaxies, the quotidian and the extraordinary have been visually represented through the ages. Medical and scientific disciplines are no exception. Accurate representation of the human body structures and anatomy based on cadaver dissections was almost not possible up to the Renaissance due to ethical, social, and religious beliefs and objections. The works of Leonardo da Vinci (1452-1519) and others and, later, Andreas Vesalius (1514-1564), who produced De Humanis Corporis Fabrica, are considered landmarks in the history of medicine. During the following centuries medical and scientific illustration relied upon the expertise of physician-artists and scientist-artists until a new paradigm appeared in the realm of scientific (medical) illustration: the invention of photography in the 19th century. Two of the medical disciplines most rapidly influenced by photography were dermatology and pathology, both macro- and microscopic. Physicians rapidly started to use photographs as a tool for consultation, documentation, and education, and large collections of images were amassed by individuals and institutions for these purposes. Photographic images are produced by visible light impressing a light-sensitive material such as a silver halide plate, and nowadays a silicon chip. But photons are reflected by nontransparent objects, including the human skin. Developments in science and technology allowed the use of other types of radiation to reveal internal structures in the human body and, most interestingly, noninvasively. Thus today much of the medical diagnosis and treatment is guided by the so-called medical imaging with the use of these techniques, that is, medical photography, endoscopy, x-ray radiography, computer-aided tomography, magnetic resonance imaging, ultrasonography, thermography, and nuclear medicine functional imaging techniques as positron emission tomography (PET) and single-photon emission computed tomography (SPECT). Some of these techniques are being applied at the microscopic level to study cell structure and even functional changes in real time. All these advancements in science and technology applied to medicine and other disciplines pose the question as to what extent physicians are trading their capabilities as clinicians. Ethics issues add to the complexity of this new era governed by constant changes in scientific paradigms.

Fifty years of brain imaging in neonatal encephalopathy following perinatal asphyxia.

In the past brain imaging of term infants with hypoxic-ischemic encephalopathy (HIE) was performed with cranial ultrasound (cUS) and computed tomography (CT). Both techniques have several disadvantages sensitivity and specificity is limited compared with magnetic resonance imaging (MRI) and CT makes use of radiation. At present MRI including diffusion weighted MRI during the first week of life, has become the method of choice for imaging infants with HIE. In addition to imaging, blood vessels and blood flow can be visualized using MR angiography, MR venography, and arterial spin labeling. Since the use of these techniques additional lesions in infants with HIE, such as arterial ischemic stroke, sinovenous thrombosis, and subdural hemorrhages can be diagnosed, and the incidence appears to be higher than shown previously. Phosphorus magnetic resonance spectroscopy (MRS) has led to the concept of secondary energy failure in infants with HIE, but has not been widely used. Proton MRS of the basal ganglia and thalamus is one of the best predictors of neurodevelopmental outcome. cUS should still be used for screening infants admitted to a NICU with neonatal encephalopathy. In the future magnetic resonance techniques will be increasingly used as early biomarkers of neurodevelopmental outcome in trials of neuroprotective strategies.

Image-Guided Interventions: We've come a long way, but are we there?

While the term "image-guided surgery" has gained popularity fairly recently, the use of imaging for medical interventions dates as far back as the beginning of the 20th century. Dr. George H. Gray of Lynn, Massachusetts, reported in his 1908 article "X-rays in Surgical Work," published in volume 2 of the Journal of Therapeutics and Dietetics, that "the one great stride in the handling of difficult cases was the accurate diagnosis made possible by the use of the X-rays." His story points to the day when a seamstress presented to his office with a broken sewing needle embedded in her hand. Thanks to the use of the recently discovered X-rays by Wilhelm Conrad Roentgen, the father of diagnostic radiology, Gray was able not only to confirm that the needle was indeed embedded in her hand but also to locate its parts, saving "an hour's hunting as some had previously done and then often failed."