Could 18F-FDG-PET/CT avoid unnecessary thyroidectomies in patients with cytological diagnosis of follicular neoplasm?

PURPOSE: Preoperative diagnosis of thyroid nodules with "follicular neoplasm" (FN) based on fine-needle aspiration cytology (FNAC) forces thyroidectomy to exclude malignancy. This study explores if (18)F-fluorodeoxyglucose positron emission tomography/computed tomography ((18)F-FDG-PET/CT) provides information enough to prevent unnecessary thyroidectomies in this clinical setting. METHODS: This is a prospective study involving 46 consecutive patients scheduled for thyroidectomy due to follicular neoplasm diagnosis in FNAC (36 follicular, 10 Hürthle cell neoplasms, Bethesda classification) since January 2009 until April 2012. All patients underwent preoperative (18)F-FDG-PET/CT. Abnormal (18)F-FDG thyroid uptake was assessed visually and by measuring the maximum standard uptake value (SUV max). Results were compared with definitive pathology reports. RESULTS: Thirteen out of 46 patients (28.3 %) were finally diagnosed with thyroid cancer. Focal uptake correlated with a greater risk of malignancy (p = 0.009). (18)F-FDG-PET/CT focal uptake showed sensitivity, specificity, positive and negative predictive values and overall accuracy of 92.3, 48.5, 41.4, 94.1 and 60.9 %, respectively. The optimal threshold SUV max to discriminate malignancy was 4.2 with an area under receiver-operating characteristic curve of 0.76 (95 % confidence interval, 0.60-0.90). Use of (18)F-FDG-PET/CT could reduce by 13-25 % the number of thyroidectomies performed for definitive benign nodules. However, it has demonstrated worse predictive ability in the subgroup of patients with diffuse uptake, oncocytic pattern in FNAC and lesions smaller than 2. CONCLUSIONS: (18)F-FDG-PET/CT can play a role in the management of thyroid nodules larger than 2 cm cytologically reported as follicular neoplasm without oncocytic differentiation, allowing the avoidance of a significant number of thyroidectomies for definitive benign lesions.

Early detection of biliary complications and graft rejection in a non-RH Identitical liver transplant recipient from a non-heart-beating donor: a case report.

Because of a shortage of organs, non-heart-beating donors have been proposed to be a possible source of grafts for orthotopic liver transplantation. Herein, we have presented a blood group A+ patient with primary biliary cirrhosis, who underwent orthotopic liver transplantation from a non-heart-beating blood group A- donor. On day 5 after transplantation the patient displayed a low hemoglobin levels as well as an increased total bilirubin with progressive encephalopathy, hypotension, and oligoanuria on day 11. The patient responded to steroid treatment. We assume the main cause of organ dysfunction was a passenger lymphocyte syndrome (ABO-Rh incompatibility). Biliary complications were detected at a 6-month follow-up visit by increased hepatic enzymes. We thus concluded that it is useful to take Rh group into account.

[Diaphragmatic hernia after transhiatal esophagectomy]. / Hernia diafragmática tras esofagectomía transhiatal.

Iatrogenic herniation of abdominal contents after transhiatal esophagectomy for the treatment of esophageal cancer is a rare complication. Its appearance in the early postoperative period is usually accompanied by acute respiratory insufficiency; herniation may develop without symptoms and the patient may have to be readmitted with signs of perforation or strangulation of the intestinal loops in the chest cavity. We report the case of a patient in this situation who developed a clinical picture of acute respiratory insufficiency and who required several exploratory procedures (fiberoptic bronchoscopy and echography) before a firm diagnosis could be made. Early diagnosis and emergency treatment reduces complications and increases survival. A lower incidence of iatrogenic herniation of abdominal contents depends on correct closure of the diaphragm. We review correct surgical treatment to decrease the frequency of this complication.

Hernia diafragmática tras esofagectomía transhiatal / Diaphragmatic herniation following transhiatal esophagectomy

La herniación iatrogénica de contenido abdominal tras la realización de esofagectomía transhiatal para el tratamiento del cáncer de esófago es una complicación poco frecuente. Su aparición en el período postoperatorio temprano suele cursar con síntomas de insuficiencia respiratoria aguda. A veces evoluciona de forma asintomática y el paciente puede reingresar con cuadro de perforación o estrangulación de las asas intestinales en la cavidad torácica. Presentamos el caso de un paciente con este tipo de intervención y cuadro de insuficiencia respiratoria aguda, que precisó de varias broncofibroscopias y ecografías antes de su diagnóstico definitivo. El diagnóstico precoz y tratamiento urgente disminuyen la morbimortalidad. El cierre correcto de la herida diafragmática es fundamental para disminuir la incidencia de dicha enfermedad. Recogemos el tratamiento quirúrgico correcto para disminuir la frecuencia de aparición de dicha complicación (AU)

Efecto de la interleucina 1ß sobre la expresión de la molécula de adhesión ICAM-1 soluble tras una agresión endotóxica experimental / Effect of interleukin 1- on expression of the adhesion molecule ICMs-1 following experimental endotoxic shock

Introducción. Durante el síndrome de respuesta inflamatoria sistémica, la célula endotelial expresa en su membrana moléculas de adhesión, favoreciendo la acción lesiva local de los leucocitos polimorfonucleares de neutrófilos. En este trabajo estudiamos el efecto que ejerce la administración de interleucina 1ß murina sobre la expresión de la molécula de adhesión intercelular (ICAM-1) soluble tras una agresión endotóxica. Material y métodos. Se han dividido 72 ratones de la cepa CBA/H en tres grupos de 24: grupo 1 (simulado); grupo 2 (control, el shock endotóxico se provocó mediante la inyección de lipopolisacárido de membrana bacteriana de Escherichia coli serotipo 055:B5 a dosis de 125 mg/kg); grupo 3 (tratado con interleucina 1ß murina a dosis de 80 ng/ratón 24 h antes del lipopolisacárido de membrana). Se han determinado, mediante la técnica de ELISA, las concentraciones séricas de ICAM-1 soluble a las 1, 2, 4 y 24 h de inyectar el lipopolisacárido. Resultados. El tratamiento con interleucina 1ß provocó un significativo descenso de las concentraciones séricas de ICAM-1 soluble a las 4 y 24 h tras la agresión endotóxica respecto al grupo control. Conclusiones. La administración de interleucina 1ß disminuye las concentraciones séricas de ICAM-1 soluble, que aparecen elevadas tras una agresión endotóxica experimental (AU)

Differential effects of IL-1 beta and ibuprofen after endotoxic challenge in mice.

Interleukin-1 (IL-1) and ibuprofen modulate the host response in different models after endotoxic challenge. A comparative study was made between the two drugs, as they were jointly administered, to explore a potentiation of their therapeutic effects. Endotoxic challenge was provoked in CBA/H mice with lipopolysaccharide (LPS) from Escherichia coli (125 mg/kg), with administration of recombinant murine IL-1 beta (80 ng/mouse) 24 hr pre-LPS. Two doses of ibuprofen (1 mg/kg) were administered 1 hr before and 30 min after the septic challenge. Serum levels of IL-1 alpha, tumor necrosis factor-alpha (TNF alpha), and interleukin-6 (IL-6) were determined 1,2, and 4 hr, post-LPS, and prostaglandin E2 (PGE2) urine levels 4,8, and 12 hr post-LPS, and a comparative mortality study was performed. IL-1 beta treatment provoked a reduction of IL-1 alpha, TNF alpha, and IL-6 without affecting PGE2, while ibuprofen provoked a later increase of IL-1 alpha, TNF alpha, and IL-6, with a decrease of PGE2. Both drugs caused a notable enhancement of survival, with no difference between them, but their combined administration caused no improvement. We conclude that both drugs exert a similar therapeutic effect in endotoxic shock by different mechanisms.

Interleukin-1beta and ibuprofen effects on CD4/CD8 cells after endotoxic challenge.

Multiple-organ failure is considered a consequence of autodestructive inflammatory response during which a state of immunosuppression is produced. Alterations in CD4 and CD8 lymphocytes after experimental endotoxic challenge and their correlation with the protective effects of interleukin-1beta (IL-1beta) and ibuprofen pretreatment were investigated. CBA/H mice were injected with lipopolysaccharide (LPS) of Escherichia coli (125 mg/kg); 40 mice were pretreated with IL-1beta (80 ng/mouse, 24 hr pre-LPS), 40 with ibuprofen (1 mg/kg 1 hr pre-LPS, 1 mg/kg 30 min post-LPS), and 40 with both drugs (same doses and timing). Prostaglandin E2 (PGE2) urine levels were determined 4, 8, and 12 hr post-LPS (10 mice), CD4 and CD8 cells 24 hr post-LPS (10 mice), and mortality at 24, 48, 72, and 96 hr (20 mice). PGE2 decreased in ibuprofen-treated groups (P < 0.05 versus control, IL-1beta groups). CD4/CD8 ratio increased in groups treated with IL-1beta (11,9) and IL-1beta plus ibuprofen (11,2) compared with sham (3,4), LPS (4,2), and ibuprofen alone (4,1) (P < 0.05). Mortality decreased in all treated groups. A correlation was observed between IL-1beta treatment, CD4/CD8 ratio, and reduced mortality. In this model IL-1beta treatment improved survival after endotoxin challenge, preventing lymphocyte derangements and increasing CD4/CD8 ratio. This effect was not potentiated by ibuprofen administration.

Variations in oxygen consumption and carbon dioxide production during parenteral nutrition.

To verify that variations caused by total parenteral nutrition (TPN) in O2 intake (VO2) and CO2 output (VCO2) can affect respiratory function of non-hypercatabolic patients, we studied 18 patients in two groups; group I (control): eight patients receiving 75-100 g glucose/24 h, and group II: ten patients fed intravenously on 13.6 g N2 and approximately 2,800 kcal/24 h given as a) 62% glucose + 38% fats (TPN-G + F) and b) 100% glucose (TPN-G). VO2, VCO2, respiratory quotient (RQ) and minute ventilation (VE) were measured in all patients. We found that VCO2 was 27% higher in intravenously fed patients (p less than 0.01 and p less than 0.02). Similarly, VE was 26% higher in intravenously fed patients (p less than 0.001 and p less than 0.02). Comparison of TPN-G + F and TPN-G results showed no differences in VCO2; by contrast, VO2 was 21% less during TPN-G (p less than 0.01).