18FDG PET/CT in the early assessment of non-small cell lung cancer response to immunotherapy: frequency and clinical significance of atypical evolutive patterns.

PURPOSE: This prospective study aimed (1) to assess the non-small cell lung cancer (NSCLC) evolutive patterns to immunotherapy using FDG-PET and (2) to describe their association with clinical outcome. DESIGN: Fifty patients with metastatic NSCLC were included before pembrolizumab or nivolumab initiation. FDG-PET scan was performed at baseline and after 7 weeks of treatment (PETinterim1) and different criteria/parameters of tumor response were assessed, including PET response criteria in solid tumors (PERCIST). If a first PERCIST progressive disease (PD) without clinical worsening was observed, treatment was continued and a subsequent FDG-PET (PETinterim2) was performed at 3 months of treatment. Pseudo-progression (PsPD) was defined as a PERCIST response/stability on PETinterim2 after an initial PD. If a second PERCIST PD was assessed on PETinterim2, a homogeneous progression of lesions (termed immune homogeneous progressive-disease: iPDhomogeneous) was distinguished from a heterogeneous evolution (termed immune dissociated-response: iDR). A durable clinical benefit (DCB) of immunotherapy was defined as treatment continuation over a 6-month period. The association between PET evolutive profiles and DCB was assessed. RESULTS: Using PERCIST on PETinterim1, 42% (21/50) of patients showed a response or stable disease, most of them (18/21) reached a DCB. In contrast, 58% (29/50) showed a PD, but more than one-third (11/29) were misclassified as they finally reached a DCB. No standard PETinterim1 criteria could accurately distinguished responding from non-responding patients. Treatment was continued in 19/29 of patients with a first PERCIST PD; the subsequent PETinterim2 demonstrated iPDhomogeneous, iDR and PsPD in 42% (8/19), 26% (5/19), and 32% (6/19), respectively. Whereas no patients with iPDhomogeneous experienced a DCB, all patients with iDR and PsPD reached a clinical benefit to immunotherapy. CONCLUSION: In patients with a first PD on PERCIST and treatment continuation, a subsequent PET identifies more than half of them with iDR and PsPD, both patterns being strongly associated with a clinical benefit of immunotherapy.

Ambulatory surgery for primary hyperparathyroidism: A 67-case series.

INTRODUCTION: Surgery for primary hyperparathyroidism, targeted by ultrasound and scintigraphy, satisfies the theoretical criteria allowing ambulatory surgery. The purpose of this study was to validate this strategy on a homogeneous case series assessed by this imaging strategy. MATERIAL AND METHODS: All patients operated for primary hyperparathyroidism by ambulatory surgery from 01/01/13 to 30/04/15 were included in this retrospective study. The usual endpoints of ambulatory surgery were evaluated. RESULTS: A total of 144 patients were operated for primary hyperparathyroidism during the study period. Ambulatory surgery was possible in 67 patients, who all had a preoperative diagnosis of parathyroid adenoma. All patients were assessed by ultrasound and 66 patients were assessed by sestamibi scintigraphy, resulting in targeted unilateral neck surgery in 98.5% of cases. Two patients had to be hospitalised overnight due to minor complications. CONCLUSION: Surgery for primary hyperparathyroidism can be performed with short operating times in carefully selected patients with a low complication rate, thereby allowing ambulatory surgery.

18F-FDOPA PET for the diagnosis of parkinsonian syndromes.

18F-FDOPA PET has been historically used for the evaluation of parkinsonian syndromes in research settings. With the wider availability of PET cameras and 18F-DOPA this method can be used as a clinical diagnostic tool. Current acquisition protocols are simple with a 10 minute static acquisition performed 90 minutes post injection. Criteria for precise visual analysis of the images are defined. The performances of the method are reviewed throughout the literature. The method is very sensitive for detection of IPD versus normal patients. Few studies comparing 18F-FDOPA PET and DAT SPECT did not show any difference in diagnostic accuracy. 18F-FDOPA PET is reliable for evaluation of IPD progression. In general, atypical Parkinson's syndromes cannot be reliably differentiated from IPD since they share a similar nigro-striatal degeneration process. However, some patterns such as the asymmetrical faint homogeneous striatal uptake reduction pattern of CBD can be recognized. The short acquisition protocol, the various indications in oncology of 18F-FDOPA and the high quality of PET images are in favor of this technique in daily clinical practice for the improvement of diagnosis of parkinsonian syndromes.

Indications of external beam radiation therapy in non-anaplastic thyroid cancer and impact of innovative radiation techniques.

BACKGROUND: The mainstay of treatment for differentiated thyroid carcinomas is surgery. There is hardly any room for radiation therapy in differentiated thyroid carcinomas. We aimed to update recommendations for RT in the context of histological variants, increased use of radioiodine and new irradiations techniques. MATERIALS AND METHODS: A search of the French and English literature was performed using thyroid carcinoma, radiation therapy, surgery, variants and radioiodine. RESULTS: Papillary, follicular, Hürthle and medullary carcinomas represent about 80%, 11%, 3% and 4% of all thyroid carcinomas, respectively. Ten-year survival rates for patients with papillary, follicular and Hürthle cell carcinomas are 93%, 85%, and 76%, respectively. The occurrence of criteria such as older age (45 or 60 years-old), massive primary disease, extensive extracapsular spread and macroscopic iodine-negative components inconsistently indicate external beam irradiation (EBRT). The impact of EBRT on poorer-prognosis histological variants is an emerging issue. Noteworthy, the incidence of laryngeal and wound healing complications has been an important limitation to EBRT. However, intensity modulated radiation therapy (IMRT) offers clear dosimetric advantages on tumor coverage and organ sparing such as the larynx, thus reducing late toxicities to less than 5%. Iodine contrast agents should be avoided during 4-6 weeks before radioiodine. PET CT is increasingly used in iodine-negative tumors. CONCLUSION: There are elective indications for EBRT and IMRT has the potential to improve local control.

Ectopic pyriform sinus parathyroid adenoma.

OBJECTIVE: To describe the diagnosis and treatment of ectopic pyriform sinus parathyroid adenoma. MATERIAL AND METHODS: A 44-year-old woman presented with persistent primary hyperparathyroidism after previous failed cervical exploratory surgery. RESULTS: Diagnosis of ectopic pyriform sinus parathyroid adenoma was suggested by computed tomography and technetium-99m sestamibi scintigraphy (99mTc-MIBI SPECT/CT). A submucosal tumor was identified under laryngoscopy and resected by endoscopic CO2 laser. Histopathology confirmed the diagnosis of parathyroid adenoma. CONCLUSIONS: Ectopic pyriform sinus locations are rare in parathyroid adenoma. 99mTc-MIBI SPECT/CT facilitates diagnosis, especially in case of previous failed neck exploration. Endoscopic CO2 laser resection is the treatment of choice.

Prognostic impact of tumour multifocality in thyroid papillary microcarcinoma based on a series of 160 cases.

OBJECTIVE: The objective of this study was to evaluate the prognostic impact of tumour multifocality in papillary thyroid microcarcinoma (PTMC). METHODS: All patients who underwent total thyroidectomy and central neck dissection for PTMC in our institution between 1990 and 2007 were included in this retrospective study. Statistical correlations between tumour multifocality and various clinical or pathological prognostic parameters were assessed by univariate and multivariate analyses. RESULTS: A total of 160 patients (133 women and 27 men; mean age: 47.8±13.7 years) were included in this study. Tumour multifocality was demonstrated in 59 (37%) patients. Central neck metastatic lymph node involvement was identified in 46 (28%) patients. No statistical correlation was demonstrated between tumour multifocality and the following factors: age, gender, tumour size, extension beyond the thyroid, metastatic central neck lymph node involvement and risk of recurrence. A tumour diameter greater than 5mm was associated with a higher risk of recurrence (P=0.008). CONCLUSION: Tumour multifocality does not appear to have a prognostic impact in PTMC.

[Papillary thyroid microcarcinomas: review of 230 cases]. / Les microcarcinomes papillaires de la glande tyroïde: à propos de 230 cas.

OBJECTIVES: Papillary microcarcinoma (PMC) is one of the most frequent pathological forms of thyroid cancer Here, we describe the circumstances of diagnosis and the clinical and pathological characteristics of this tumour We also analyze the therapeutic management and compare it with the recent published guidelines. METHODS: Between 2000 and 2006, a total of 230 patients with a PMC of the thyroid gland were included in this retrospective study. We have investigated the correlations between some pathological parameters (plurifocality, lymph node invasion...) and several factors (age, gender, tumour size...). RESULTS: The diagnosis of PMC was suspected in the preoperative period in 15% of the patients, and was confirmed intraoperatively by the pathologist in 42% of the cases. Plurifocal or bilateral PMC were discovered in respectively 30 and 17% of the patients. The rate of lymph node invasion in the central neck (level VI) was 26%. An elevated tumor size was correlated with a higher rate of plurifocal or bilateral PMC and of lymph node metastasis (p < 0.05). The indications for postoperative radioiodine therapy were reduced by approxiately 50% in the second part of our study. There were no case of thyroid PMC-related death. CONCLUSIONS: Even for these small tumours, tumour size remains correlated with the tumour aggressiveness. The place of radioiodine therapy in the management of thyroid PMC was progressively reduced because of the good prognosis of this tumour.

Long-term radiographic follow-up in a patient with osteosclerotic sarcoidosis of the spine and pelvis.

Eight-year clinical and radiographic data in a patient with sarcoidosis manifesting as pelvic and spinal osteosclerosis and as mediastinal lymphadenopathy are described, extending the initial report of this case written after three years of follow-up. The osteosclerotic lesions involved the right iliac and sacral wings, as well as two lumbar vertebras, which had an ivory appearance. There was also evidence of right sacroiliitis, pubic symphysitis and T7-T8 discitis. The diagnosis was established by bone and mediastinal lymph node biopsies. Follow-up was eight years at the time of this writing. The osteosclerotic lesions improved, disappearing almost completely at the lumbar spine, and fusion occurred at the right sacroiliac joint, pubic symphysis, and T7-T8 intervertebral disk. A review of the literature found 13 similar cases, with noticeably shorter follow-ups. The characteristics of axial osteosclerotic sarcoidosis are reviewed, and the indications of corticosteroid therapy are discussed.