Advances in diagnostic practices affect thyroid cancer incidence in France.

OBJECTIVE: To analyse trends in diagnostic practices of thyroid diseases and to relate them to the increase in thyroid cancer incidence in France over time. DESIGN: From 1980 to 2000, a French retrospective multicentric (three endocrinology and three nuclear medicine centres) study of thyroid diseases was conducted on 20 consecutive unselected patients' records, sampled every 5 years in each centre. METHODS: Characteristics of the population and diagnosis procedures (thyroid ultrasonography (US), radionuclide scan, cytology and hormonal measurements) were described over time. Changing trends in operated patients and in cancer prevalence were analysed as well as the impact of practices on cancer incidence. RESULTS: The study included 471 patients (82% female, mean age 46.7, range 9-84 years), referred for nodular thyroid diseases (66.7%) or thyroid dysfunctions (33.3%). A significant increase in US (3 to 84.8%) and cytological practices (4.5 to 23%), and a decrease (89.4 to 49.6%) in radionuclide scan procedures were observed over time. Although the proportion of patients undergoing surgery remained constant (24.8%), the prevalence of cancer increased among operated patients from 12.5 to 37% (P=0.006). In a Cox's proportional hazard model stratified on the clinical characteristics of patients, only the cytological practice, regardless of its results, was significantly associated with the occurrence of cancer: relative risk (RR)=4.4 (95% confidence interval (CI): 1.1-16; P=0.04). CONCLUSIONS: From 1980 to 2000, a major evolution in clinical practices has led to the increase in thyroid cancer reported in France. Such changes in medical, as well as in surgical and pathological, practices must be taken into account in incidence measurement.

[Value of the prosthetic patch after carotid endarterectomy]. / Intérêt du patch prothétique après endartériectomie carotidienne.

INTRODUCTION: Carotid patching after carotid endarterectomy remains a subject of controversy. However the recent medical literature shows that carotid patching lowers the incidence of both residual stenosis and early restenosis. Carotid patching seems also to lower the incidence of postoperative carotid occlusion. Some authors advocate systematic patching, others recommend a more selective use of carotid patching, among patients with small caliber carotid artery and among those with restenosis. STUDY: We have realized this study to determine (1) the incidence of restenosis after direct closure in patients with internal carotid artery of more than 3.5 mm internal diameter, (2) the adequate size of the patch in carotid arteries of less than 3.5 mm interval diameter (3), the adequate material to use for carotid patching. To answer these questions, we have done a prospective study of 188 carotid endarterectomy comparing direct closure (Group A), saphenous patch (Group B), and prosthetic Gore-Tex patch (Group C) with randomization between saphenous and prosthetic patch. RESULTS: In this study we were unable to show any difference among the three groups concerning postoperative mortality and neurologic complications. However we have been able to show more residual stenosis in group A than in groups B and C. One saphenous patch rupture occurred in Group B. After one year follow-up, five out of 43 restenosis occurred in Group A (11.6%). The rate of restenosis in groups B and C was 1.5% (2/135). In group B, six patients (8.7%) had a dilatation of the saphenous patch of more than 50% of their initial diameter. CONCLUSIONS: In this study, carotid patch seems to lower the incidence of residual stenosis and early restenosis in small diameter internal carotid arteries. Carotid patching with a 5 mm diameter PTFE patch seems to be the ideal choice after carotid endarterectomy. Furthermore, prosthetic patching carry no risk of dilatation or rupture and spare the saphenous vein.