Normal Parathyroid Glands Are Most Often Seen on Neck Ultrasound.

RATIONALE AND OBJECTIVES: The dogma is that normal parathyroid glands (PTGs) are not visible on ultrasound (US). Recently, several studies have shown that PTGs present these US features: ovoid structure, homogeneous and hyperechoic. The primary objective was to assess the detection rate, standard size and locations of normal PTGs in a population of patients consulting for thyroid US exam. The secondary objective was to determine if the presence of a goiter or a thyroiditis could modify the visualization of normal PTGs. METHOD: Single-center prospective study on 192 patients based on the typical US appearance previously described to identify one or more PTGs. RESULTS: One or more PTGs were visualized in 75% of patients (144/192). They were visualized preferentially at the lower pole of the thyroid gland and in the infra-thyroid region (66%). The mean (± SD) size of normal PTGs was 5.68 mm (± 1,42 mm)×4.05 mm (± 1,03 mm)×2,68 mm (± 0,61 mm) and mean volume was 33.3 mm3 (± 17.75 mm3). The presence of a goiter made the search for PTGs more difficult whereas the presence of thyroiditis facilitated it. CONCLUSION: The US detection rate of PTGs is high (75%). The identification of PTGs could be particularly useful in the preoperative assessment before total thyroidectomy or parathyroid surgery. It could reduce the risk of postoperative hypoparathyroidism and improve the accuracy of postoperative US surveillance of thyroid cancer. Better knowledge of the usual anatomical location of normal PTGs could also enable better detection of abnormal glands.

Outcomes of active surveillance of EU-TIRADS 5 thyroid nodules.

OBJECTIVE: Active surveillance of cytologically proven microcarcinomas has been shown as a safe procedure. However, fine needle aspiration biopsy (FNAB) is not recommended by European Thyroid Association (ETA) and American Thyroid Association (ATA) guidelines for highly suspicious nodules ≤ 10 mm. The aim of the study was to assess the outcomes of active surveillance of EU-TIRADS 5 nodules ≤ 10 mm not initially submitted to FNAB. PATIENTS AND METHODS: 80 patients with at least one EU-TIRADS 5 nodule ≤ 10 mm and no suspicious lymph nodes, accepting active surveillance, were included. RESULTS: Mean baseline diameter and volume were 5.4 mm (±2.0) and 64.4 mm3 (±33.5), respectively. After a median follow-up of 36.1 months, a volumetric increase ≥ 50% occurred in 28 patients (35.0%) and a suspicious lymph node in 3 patients (3.8%). Twenty-four patients underwent an FNAB (30.0%) after at least a 1 year follow-up of which 45.8% were malignant, 8.3% benign, 33.3% undetermined and 8.3% nondiagnostic. Sixteen patients (20.0%) underwent conversion surgery after a median follow-up of 57.2 months, confirming the diagnosis of papillary carcinoma in 15/16 cases (not described in 1 histology report), all in remission at 6-12 months postoperative follow-up. CONCLUSION: Applying ETA and ATA guidelines to avoid FNA of EU-TIRADS 5 sub-centimeter nodules and proceeding to active surveillance of such nodules in selected patients is a safe procedure. Thus, US-FNAB could be postponed until the nodule shows signs of progression or a suspicious lymph node appears, with no added risk for the patient.

TIRADS score is of limited clinical value for risk stratification of indeterminate cytological results.

CONTEXT: Thyroid nodules with cytological indeterminate results represent a daily and recurrent issue for patient management. OBJECTIVE: The primary aim of our study was to determine if TIRADS (Thyroid Imaging Reporting and Data System) could be used to stratify the malignancy risk of these nodules and to help in their clinical management. Secondary objective was to estimate if this risk stratification would change after reclassification of encapsulated non-invasive follicular variant of papillary carcinomas (FVPTC) as non-invasive follicular thyroid neoplasm (NIFTP). PATIENTS AND METHODS: Single-center retrospective study of a cohort of 602 patients who were referred for ultrasound-guided fine-needle aspiration from January 2010 to December 2016 with an indeterminate cytological result and in whom histological results after surgery were available. TIRADS score was prospectively determined for all patients included. Nodules that had been classified as FVPTC were submitted to a rereading of histological report and reclassified as NIFTP when judged relevant. A table of malignancy risk crossing Bethesda and TIRADS results was built before and after this reclassification. RESULTS: The study included 602 cytologically indeterminate nodules. TIRADS score was positively correlated with the malignancy rate (P < 0.0001). Risk stratification with TIRADS was significant only in Bethesda V nodules (P = 0.0004). However, the risk of malignancy in this Bethesda V category was always above 45%, whatever the TIRADS score. CONCLUSION: For a clinician facing an indeterminate cytological result for a thyroid nodule, return to TIRADS score is of limited value in most conditions to rule in or rule out malignancy and to guide subsequent management of patients.

[The Thyroid Imaging Reporting and Data System (TIRADS) for ultrasound of the thyroid]. / Le système TIRADS en échographie thyroïdienne.

PURPOSE: To develop a standardized system for analyzing and reporting thyroid ultrasound, or Thyroid Imaging Reporting and Data System (TIRADS), in order to improve the management of patients with thyroid nodules. MATERIALS AND METHODS: An atlas of imaging features, a standardized vocabulary, a report template and TIRADS categories 0 to 6 were defined, based on the BI-RADS system used for mammography. The diagnostic efficacy of the system was tested by a retrospective review of 500 nodules (159 cancers and 341 benign nodules) and comparing US imaging features to histological findings. RESULTS: Five signs allow accurate detection of 90% of thyroid cancers. The score of a nodule can be easily defined by using an organigram. Sensitivity, specificity and odds-ratio of the score were respectively 95%, 68% and 40. CONCLUSION: TIRADS is a quality assurance tool for thyroid ultrasound. It contains an image atlas, a standardized report and categories to evaluate thyroid nodules to easily assess the risk of individual nodules being cancers and facilitate patient management.

Good practice guide for cervical ultrasound scan and echo-guided techniques in treating differentiated thyroid cancer of vesicular origin.

Good practice guide for cervical ultrasound scan and echo-guided techniques in treating differentiated thyroid cancer of vesicular origin. American, European and French Recommendations for the treatment of differentiated vesicular thyroid cancer were recently published. Cervical ultrasound scanning is now considered a key examination in the follow-up of these cancers. This examination is noninvasive, easy to perform and to obtain, is not costly, but remains operator-dependent. To date, there are no recommendations published that assemble all the technical aspects, results, indications and the limits of this examination in the initial medical report and the follow-up of these cancers. In order to standardise the procedure and validate the quality of the examination, a workgroup made up of a panel of experts particularly involved in carrying out ultrasound scans was set up. The aim was to draw up a good practice guide for performing cervical ultrasound scans and echo-guided techniques in treating patients with differentiated thyroid cancer of vesicular origin. The main objectives are to: (a) standardise the procedure and reports, (b) define the criteria for establishing whether lesions identified during a cervical ultrasound scan are malignant or benign, (c) standardise the indications for carrying out cytological tests and an in situ assay of markers, (d) help doctors to select the patients who ought to receive a cervical ultrasound scan and or cytological tests, (e) discuss how frequently the examinations should be carried out depending on the risk of recurrence.

Minimally invasive ablation of a toxic thyroid nodule by high-intensity focused ultrasound.

HIFU is used in the treatment of cancer (prostate, breast) and uterine fibroma but not yet in TNs. This case report describes the first successful ablation of a toxic TN with HIFU. TSH and radioiodine scan normalization were achieved without complications and maintained for 18 months. HIFU treatment is a minimally invasive technique that may be an effective safe alternative to radioiodine or surgery in patients with toxic TNs.

[Hand-foot syndrome: A new side effect of erlotinib]. / Syndrome mains-pieds : nouvel effet secondaire de l'erlotinib.

BACKGROUND: Erlotinib (Tarceva) belongs to the family of epidermal growth receptor factor (EGFR) inhibitors. Used in the treatment of some cancers, it is responsible for several cutaneous side effects. We report a case of hand-foot syndrome, which has not previously been described with this drug to our knowledge. PATIENTS AND METHODS: A 65-year-old patient was given erlotinib for lung cancer and after the first month of treatment, he developed severe hand-foot syndrome. DISCUSSION: Hand-foot syndrome consists of abrupt bilateral and painful acral erythema associated with dysesthesia. It is a dose-dependent side effect of certain cytostatic drugs. It may sometimes require withdrawal of the causative drug. Care must be taken to identify the early signs of hand-foot syndrome in patients treated with erlotinib.

Clinical spectrum of gammadelta+ T cell LGL leukemia: analysis of 20 cases.

We report on the clinico-biological characteristics of 20 cases of gammadelta T cell large granular lymphocyte (LGL) leukemia. All the data were compared to that of 196 cases with alphabeta T cell subtype, which represents the majority of T cell LGL leukemias. Clinical findings were quite similar in the two groups regarding age, sex ratio, recurrent infections, and association with auto-immune diseases especially rheumatoid arthritis. Gammadelta LGL predominantly expressed a CD3+/CD4-/CD8+/CD16+/CD57+ phenotype, in 50% of cases. Clinical outcome was favorable for these patients with overall survival of 85% at 3 years. Fifty percent of gammadelta patients required treatment and the response to therapy was estimated at 55%. gammadelta and alphabeta T cell LGL leukemia harbor a very similar clinico-biological behavior and represent part of an antigen-driven T cell lymphoproliferation.

Hormonal treatment of congenital adrenal hyperplasia due to 21-hydroxylase deficiency.

During childhood, the main aims of the medical treatment of congenital adrenal hyperplasia (CAH) secondary to 21-hydroxylase deficiency, are to prevent salt loss and virilization and to achieve normal stature and normal puberty. As such, there is a narrow therapeutic window through which the intended results can be achieved. In adulthood, the clinical management has received little attention, but recent studies have shown the relevance of long-term follow-up of these patients. Indeed, long-term evaluation of adult CAH patients enables the identification of multiple clinical, hormonal and metabolic abnormalities as bone mineral density alteration, overweight and disturbed reproductive functions. In women with classic CAH, low fertility rate is reported, and is probably the consequence of multiple factors, including neuroendocrine and hormonal factors, feminizing surgery, and psychological factors. Men with CAH may present hypogonadism either through the effect of adrenal rests or from suppression of gonadotropins resulting in infertility. These patients should therefore be carefully followed-up, from childhood through to adulthood, to avoid these complications and to ensure treatment compliance and tight control of the adrenal androgens, by multidisciplinary teams who have knowledge of CAH.

Smoking cessation or reduction in women attempting to conceive after ectopic pregnancy.

The relationship between smoking cessation or reduction and attempt to conceive was studied in 646 women treated for ectopic pregnancy (EP) (Auvergne register of EP, France). Women were prospectively followed. Tobacco consumption was recorded as the mean number of cigarettes smoked per day at the time of interview. Smoking reduction was defined as stopping smoking or decreasing tobacco consumption by at least 3 cigarettes per day. Statistical analysis was performed using conditional logistic regression. The results confirmed that women reduced tobacco consumption when they became pregnant. However, no association was found between smoking reduction and attempting to conceive again. These results suggest that both women and physicians need to be informed about the possible tobacco consumption effects of smoking on fertility.

Changes in culturability and virulence of Salmonella typhimurium during long-term starvation under desiccating conditions.

The survival of Salmonella typhimurium under desiccation and starvation conditions commonly associated with farm buildings was investigated in a desiccation model system: filtration onto polycarbonate membranes placed in a sealed desiccator with 0.0067 g/m3 absolute humidity. Heterogeneities within bacterial populations in relation to time of desiccation were investigated on a single-cell basis by epifluorescence microscopy coupled with an image analysis system in conjunction with fluorescent dyes Chemchrome V6 and DAPI. Changes in cellular states were compared to the results of plate counts (colony forming units, CFU) on selective (modified semi-solid Rappaport Vassiliadis (MSRV)) and non-selective (nutrient agar (NA) and R2A agar) media, and to the measurements of infectivity and virulence using two animal models (chicks and mice). During 9 weeks of experimental desiccation, total cell counts (DAPI) of starved S. typhimurium remained stable, as did esterase activity (Chemchrome V6), but DAPI fluorescence intensity decreased slowly. Bacterial cells entered gradually into non-culturable states (decrease of CFU counts on MSRV, NA and R2A agar media) and the total loss of culturability on NA (defined as probability of presence of 1 CFU on the membrane inferior to 10 (-6)) was obtained after 9 weeks. Loss of chick infectivity and mice virulence in animal models occurred more rapidly, within three weeks of experimental desiccation.

[A simple detubularized ileal neobladder]. / Une technique simple de néo-vessie iléale détubulée.

Generalized use of bladder replacement techniques has turned Cystoprostatectomy into a less mutilating operation and made its indication easier, particularly in patients with bladder carcinoma. The authors propose an easy way of detubularizing an ileal loop by mechanical section-suture with the GIA*, resulting in a good capacity neobladder by a simple and quick operation. Results of this technique in 38 Patients, with a mean follow-up of 13.5 months (2 to 36.9 months), point out its reliability, good tolerance of the high urinary tract and obtaining of a satisfying continence in most of the patients. The only real risk, that is stone formation on staples, seem negligible according literature, and only one case was observed in this series urodynamic results are presented and do not seem in close relation with clinical state, nor having any predictive value. At last considerations on cystoplasties continence are discussed, and nocturnal continence of neobladders is debated.

Steroid-cyclophosphamide pretreatment of kidney allograft donors. A control study.

34 cadaveric donor grafts were randomized in a blind study of the effect of pretreatment of 5 g each of methylprednisolone and cyclophosphamide on kidney graft outcome. There was no difference in overall survival or functioning after 3, 6 or 12 months between grafts from pretreated (33 kidneys) or control (29 kidneys) cadaveric donors. In addition, this pretreatment protocol did not modify the recipient immune response against B-lymphocyte alloantigens which developed in unsuccessful transplants. Our data, thus, neither confirm the high rate of kidney graft survival attributed to cadaveric donor treatment nor the supposition that treatment is effective in suppressing recipient antidonor B-lymphocyte antibodies.