Tumour and pelvic lymph node metabolic activity on FDG-PET/CT to stratify patients for para-aortic surgical staging in locally advanced cervical cancer.

PURPOSE: The aim of our study was to comprehensively evaluate the most valuable metabolic parameters of cervical tumours and pelvic lymph nodes (PLN) by FDG-PET/CT to predict para-aortic lymph node (PALN) metastasis and stratify patients for surgical staging. METHODS: The study included patients with locally advanced cervical cancer, negative PALN uptake on preoperative FDG-PET/CT, and para-aortic lymphadenectomy. Two senior nuclear medicine physicians expert in gynaecologic oncology reviewed all PET/CT exams, and extracted tumour SUVmax, MTV, and TLG, as well as PLN. Prognostic parameters of PALN involvement were identified using ROC curves and logistic regression analysis. RESULTS: One hundred and twenty-five consecutive locally advanced cervical cancer patients were included. The FDG-PET/CT false-negative rate was, respectively, 27.7% (13/47) and 5.1% (4/78) in patients with and without FDG-PET/CT PLN uptake. The AUC of cervical tumour size, SUVmax, MTV, and TLG was, respectively, 0.75 (0.62-0.87), 0.59 (0.44-0.76), 0.75 (0.60-0.90), and 0.71 (0.56-0.86). The AUC of PLN size, SUVmax, SUVmean, PLN SUVmax/Tumour SUVmax ratio, MTV, and TLG was, respectively, 0.57 (0.37-0.78), 0.82 (0.68-0.95), 0.77 (0.61-0.94), 0.85 (0.72-0.98), 0.69 (0.51-0.87), and 0.74 (0.57-0.91). The metabolic parameter showing the best trade-off between sensitivity and specificity to predict PALN involvement was the ratio between PLN and tumour SUVmax. CONCLUSION: The risk of PALN metastasis in FDG-PET/CT negative PLN patients is very low, so para-aortic lymphadenectomy does not seem justified. In patients with preoperative PLN uptake on FDG-PET/CT, surgical staging led to treatment modification in more than 25% of cases and should therefore be performed. Patients with more than one positive PLN and high PLN metabolic activity are at high risk of para-aortic extension and recurrence. Further prospective evaluation is required to consider intensified treatment modalities without prior PALN dissection.

[Previa uterine leiomyoma: a rare case of bowel obstruction during pregnancy]. / Fibrome prævia : une cause rare d'occlusion intestinale aiguë en cours de grossesse.

We report the case of a massive posterior leiomyoma leading to a bowel acute obstruction and an obstructive renal failure in a 33 years old primigest woman during pregnancy. The patient underwent a urinal and an intestinal derivation during de second trimester of pregnancy as a conservative management. End of pregnancy was uneventful and she gave birth to an healthy boy (2345g) at term, by cesarean section for praevia leiomyoma. The myoma was removed 6 weeks after delivery with restoration of digestive continuity in the same time. This case report shows the morbidity of 10cm and larger leiomyoma during pregnancy.

[Indications for electrophysiological investigation of tachycardia]. / Indications des explorations électrophysiologiques dans les tachycardies.

Cardiologists are often confronted by the situation of discussing the indications for invasive electrophysiological procedures. In this field, the recommendations of American scientific societies have been published but they are relatively dated and require updating. These procedures require the introduction of one or more catheters by a femoral venous or arterial approach, or by the endoesophageal route for positioning at different sites in the heart. The first stage of the procedure is usually to evaluate the electrophysiological properties of the cardiac chamber under investigation; followed by provocative manoeuvres such as electrical stimulation, injection of a drug, the delivery of a CEE electrical shock percutaneously or by an intracardiac radiofrequency stimulation, according to the type of procedure or the centre concerned. Schematically, the indications of these procedures may be determined in different contexts according to the benefits that may be expected in a given clinical situation. This article is devoted to the principal rhythmological situations which may be encountered but, however, the indications of radiofrequency ablation are not discussed.

How smart should pacemakers Be?

The concept of the "smart" pacemaker has been continuously changing during 40 years of progress in technology. When we talk today about smart pacemakers, it means optimal treatment, diagnosis, and follow-up for patients fitting the current indications for pacemakers. So what is smart today becomes accepted as "state of the art" tomorrow. Originally, implantable pacemakers were developed to save lives from prolonged episodes of bradycardia and/or complete heart block. Now, in addition, they improve quality of life via numerous different functions acting under specific conditions, thanks to the introduction of microprocessors. The devices have become smaller, with the miniaturization of the electrical components, without compromising longevity. Nevertheless, there are still some unmatched objectives for these devices, for example, the optimization of cardiac output and the management of atrial arrhythmias in dual-chamber devices. Furthermore, indications continue to evolve, which in turn require new, additional functions. These functions are often very complex, necessitating computerized programming to simplify application. In addition, the follow-up of these devices is time-consuming, as appropriate system performance has to be regularly monitored. A great many of these functions could be automatically performed and documented, thus enabling physicians and paramedical staff to avoid losing time with routine control procedures. In addition, modern pacemakers offer extensive diagnostic functions to help diagnose patient symptoms and pacemaker system problems. Different types of data are available, and their presentation differs from one company to the other. This huge amount of data can only be managed with automatic diagnostic functions. Thus, the smart pacemaker of the near future should offer high flexibility to permit easy programming of available therapies and follow-up, and extensive, easily comprehensible diagnostic functions.

[Cardiac involvement in malignant non-Hodgkin's lymphoma]. / Atteintes cardiaques des lymphomes malins non hodgkiniens.

Selective cardiac involvement by a malignant non-Hodgkin's lymphoma (primary lymphoma of the heart) is extremely rare. Cardiac lesions occurring in the course of a malignant non-Hodgkin's lymphoma (secondary lymphoma of the heart) are found at autopsy in about 10 per cent of the cases. Secondary lymphoma of the heart may involve all cardiac structures, but lesions of the right heart, and particularly the right atrium, are predominant. Clinical manifestations are usually non-specific and appear at a late stage, reflecting diffuse involvement. When the malignant non-Hodgkin's lymphoma is known, systematic two-dimensional echocardiography should easily detect the lymphomatous cardiac infiltration, irrespective of the presence or absence of symptoms. When the malignant non-Hodgkin's lymphoma is unknown, only histology can show that the heart tumour is a lymphoma, evaluate its extension and confirm that it is limited to the cardiac walls, provided the disease is treated at an early stage, prolonged complete remissions are observed after chemotherapy and/or radiotherapy.

[Cardiac sarcoidosis responsible for localized left ventricular ectasia and refractory ventricular tachycardia. Anatomoclinical study]. / Sarcoïdose cardiaque responsable d'une ectasie ventriculaire gauche localisée et de tachycardies ventriculaires réfractaires. Etude anatomo-clinique.

The authors report the case of a 63 year old woman admitted to hospital for recurrent refractory ventricular tachycardia. Echocardiography and cardiac scintigraphy showed global left ventricular function. Ventriculography confirmed the left ventricular dysfunction and also showed a localised aneurysm of the anterior left ventricular wall. Surgical resection of the aneurysm and an encircling endocardial ventriculotomy were performed but the patient died of a low output syndrome. Pathological examination of the excised tissue showed granulomatous lesions associated with fibrosis interrupting the striated myocardial bundles. The granulomata consisted in a large number of epithelioid histiocytes and very large giant cells with many nuclei. The diagnosis made retrospectively was that of cardiac sarcoidosis causing a ventricular aneurysm and global left ventricular dysfunction. The diagnosis of cardiac sarcoidosis is difficult in the absence of systemic extracardiac involvement because the clinical manifestations and complementary investigations are non specific. The diagnosis may be made by endomyocardial biopsy in 25 per cent of cases, thereby leading to specific treatment with steroids which is sometimes effective.