Edgard Coche

PET-FDG scan enhances but does not replace preoperative surgical staging in non-small cell lung carcinoma.

OBJECTIVEnTo assess the effectiveness of positron emission tomography with radiolabeled [18F]-2-fluoro-deoxy-D-glucose (PET-FDG) imaging in mediastinal lymph node (LN) staging for non-small cell lung carcinoma (NSCLC) and to compare it to conventional clinical and surgical staging.nnnMETHODSnFrom June 1998 to February 2000, we enrolled 64 potentially resectable NSCLC patients in a prospective study of PET-FDG imaging of the mediastinum to assess LN involvement. Results of this technique were compared to conventional clinical and surgical staging. Diagnostic efficacy was determined by calculating sensitivity, specificity, overall accuracy, and positive and negative predictive values for each method.nnnRESULTSnPET-FDG imaging correctly identified nodal stage (N0-N1 vs. N2) in 50 out of 61 patients (82%), overstaging occurred in eight patients (13%), and understaging in three patients (4.9%). The sensitivity, specificity, accuracy, and positive and negative predictive values for PET-FDG scan imaging were 67, 85, 82, 43, and 93.6%, respectively. Conventional staging correctly identified nodal stage (N0-N1 vs. N2) in 51 out of 62 patients (82%), overstaging occurred in five patients (8.1%), and understaging in six patients (9.7%). The sensitivity, specificity, accuracy, and positive and negative predictive values for conventional staging were 33, 90.6, 82, 37, and 89%, respectively. With regard to N2 disease, conventional staging showed a poor sensitivity (33%). Indeed, six out of 64 patients were understaged for mediastinal LN involvement. Even though the improvement was not statistically significant (McNemar P=0.08), the combined use of PET-FDG scan and computerized tomography (CT) scan allowed a two-fold increase in the sensitivity of our clinical preoperative staging. Moreover, relying on the PET-scan high negative predictive value might have contributed to a three-fold decrease in the number of required surgical staging procedures.nnnCONCLUSIONSnOur study shows that the PET-FDG imaging strength lies in its very high negative predictive value and increased sensitivity. In this study, the overall accuracy of PET-FDG scan (82%) was lower than previously reported. Combined with chest CT-scan preoperatively, it may alleviate the need for surgical staging when PET-FDG studies of the mediastinum are negative. However, with a positive PET-FDG scan result, further diagnostic procedures should be pursued in order to avoid overstaging and allow better surgical patient selection.

Calcifying fibrous pseudotumor (CFPT): a patient presenting with multiple pleural lesions.

Calcifying fibrous pseudotumor (CFPT) is a rare pseudotumoral lesion initially described in the subcutaneous and deep soft tissues. More recently, 3 cases were reported in the pleura. We report an unusual presentation associating miliary pleural lesions with a single soft tissue lesion in a 29-year old, asymptomatic female patient. The multitude of pleural lesions prevented complete excision. Although the present case confirms an indolent process, the pathogenesis and long-term prognosis remain undetermined.

Contributions of the video-assisted approach to thyroid and parathyroid surgery.

Abstract Background: The authors report their initial experience with partial and total thyroidectomy, and neck exploration for hyperparathyroidism using the video-assisted approach. Patients and methods: Between June 1999 and March 2001, 114 patients underwent a thyroid (n = 57) or parathyroid (n = 57) operation using a video-assisted cervical approach. Video-assisted neck exploration was conducted in all cases under general anaesthesia leading to a partial or total thyroidectomy, and to a selective adenoma removal in PHPT or to a subtotal parathyroid resection in SHPT. Results: In the thyroid group: the mean cranio-caudal and transversal diameter of the resected specimen were respectively 4.9 ± 0.9 and 2.8 ± 0.6 cm, and mean total lobar weight was 11.7 ± 5.8g. Conversion to conventional surgery was required in 5 patients (8,8%). The mean operative time was 133,9 ± 26,9 and 86,5 ± 22,5 minutes for total and partial thyroidectomy respectively. The laryngeal nerve was identified in 96% of cases. The mean length of skin incision was 24.0 ± 2 mm. There were 3 cases of postoperative hypocalcemia, and 2 cases of postoperative hoarseness. The postoperative hospital stay was less than 24 hours for 72.7% of patients. The pain intensity at day one (VAS) was 2.1 ± 1.3. In the parathyroid group: seven of the 44 patients who underwent PHPT (15.9%) and 4 of the 13 patients who underwent surgery for SHPT (30.8%) were converted to a conventional surgical technique. The mean operative time in PHPT and SHPT was 47.3 ± 22.3 minutes and 136.8 ± 18.7 minutes, respectively. Recurrent laryngeal nerve was identified in 53.1% of the patients. The median diameter and weight of the resected parathyroid glands were 1.5 cm (range 0.8–2.7) and 0,9 g (range 0.5–7), respectively. The length of skin incision was 24 ± 2mm. All but 2 patients are currently cured. Postoperative complications included hematoma and transient hoarseness each in one patient (1.75%). The median pain intensity at day one (VAS) was 0.5 (range: 0 to 3.6). In the PHPT group, the postoperative hospital stay was less than 24 hours for 56.7% of the patients, and less than 48 hours for 91.9% of them. Conclusion: The video-assisted approach for thyroid and parathyroid surgery is feasible, safe and effective in selected cases. Benefits for the patients should be further assessed in future prospective comparative trials.

To control or to be controlled? From health locus of control to morphine control during patient-controlled analgesia.

We postulated that patients with an internal locus of control, i.e. those who like to control their health problems themselves, would adapt more adequately to the patient-controlled analgesia technique as compared to patients with an external health locus of control, who do not believe in their own control. Since contradicting studies have been published on this matter, we investigated relations between the demand for analgesics, perceived pain in the postoperative phase, and the health locus of control in the postoperative context of cardiac surgery. Findings demonstrate distinct utilization patterns between subjects with internal or external locus of control concerning total morphine consumption, number of unsatisfied demands and reduction of perceived pain.

Video-assisted neck exploration for primary and secondary hyperparathyroidism: initial experience.

Background: Minimally invasive surgery (MIS) for primary hyperparathyroidism includes unilateral neck exploration, access via a totally endoscopic approach, and access via a video-assisted procedure. We report herein our initial experience with the video-assisted neck exploration procedure for primary (PHPT) and secondary hyperparathyroidism (SHPT). Methods: Between June 1999 and May 2000, 35 patients were selected for PHPT (n = 25) and SHPT (n = 10). In all cases, video-assisted neck exploration was performed under general anesthesia, leading to selective adenoma removal in PHPT or subtotal parathyroid resection in SHPT. Patient selection was based on the preoperative localization studies (ultrasonography and sestamibi scintigraphy). Results: Five of the 25 patients operated on for PHPT (20%) and three of the 10 patients who underwent surgery for SHPT (30 %) were converted to a conventional surgical technique. The mean operative times in PHPT and SHPT were 48.9 ± 18.7 min and 136.8 ± 18.7 min, respectively. The recurrent laryngeal nerve was identified in 45% of the patients. The median size and weight of the resected parathyroid glands were 1.8 cm (range, 0.9-2.5) and 1 g (range, 0.5-7), respectively. The length of skin incision was 24 ± 1.2 mm. All but one patient are currently cured, with a median follow-up of 6 months (range, 2-13). Postoperative complications included hematoma and transient hoarseness in one patient each (2.85%). The median pain intensity, based on the visual analogue scale (VAS) method, as measured at postoperative day 1 was 0.5 (range, 0-3.6). In the PHPT group, the postoperative hospital stay was <24 h for 30% of the patients and <48 h for 80% of them. conclusion: video-assisted unilateral and bilateral neck exploration is feasible and safe; it represents an attractive and promising minimally invasive approach in phpt and shpt when the surgeon follows the same rules used in the standard conventional approach. its early benefits and long-term results still need to be compared to those of the conventional procedure in a randomized trial.

Sélection et délimitation des volumes–cibles anatomocliniques ganglionnaires dans les tumeurs de la sphère cervico-maxillo-faciale

This article reviews all clinical and pathological data available in the literature supporting the concept of selectivity in the neck nodes to be included in the Clinical Target Volume for head and neck squamous cell carcinoma. Using the terminology of neck node levels and the guidelines for the surgical delineation of these levels proposed by the Committee for Head and Neck Surgery and Oncology of the American Academy for Otolaryngology-Head and Neck Surgery, recommendations are proposed for both the selection and the delineation of lymph node target volumes.

Rentabilité des prélèvements histologiques au cours de la sarcoïdose: Analyse rétrospective multicentrique de 618 biopsies pratiquées chez 416 malades

Resume Le diagnostic de sarcoidose necessite lobtention dune preuve histologique de granulome epithelioide. Lanalyse retrospective de 618 biopsies pratiquees chez 416 patients atteints de sarcoidose montre que la rentabilite moyenne de ces biopsies est de 69 p. 100. La rentabilite des biopsies « a laveugleest moindre: elle croit avec le degre dagressivite de lexamen pratique, de 49 p. 100 (biopsie bronchique proximale) a 70 p. 100 (ponction biopsie hepatique). En labsence durgence therapeutique, le test de Kveim reste un examen anodin, assez sensible (65 p. 100) et peu couteux.

Fifteen years of inpatient care in an academic division of general internal medicine: 1980-1994. Trends over time in patient's diagnoses, case-severity, case-complexity and mortality rate.

We describe the trends over time in patients diagnoses, case-complexity, case-severity, length of stay and mortality rate during the last 15 years in an academic division of general internal medicine (GIM). Our study shows that GIM patients presented with a broad spectrum of diseases. Moreover, important changes were observed in the patient characteristics, i.e. a progressive increase in urgent admissions, severe medical conditions and elderly population. This evolution was associated with a significant rise in case-severity and case-complexity which explains the observed increase in hospital mortality rate. These variables should be accounted for when analyzing processes and outcomes of inpatient medical care in internal medicine.

Acute cholestatic hepatitis with rash and hypereosinophilia associated with ranitidine treatment

We report a case of acute cholestatic hepatitis associated with rash and hypereosinophilia, in which the absence of transfusion, intercurrent viral infection, alcohol consumption or other hepatotoxic drugs are suggestive of ranitidine-induced hepatotoxicity. The pathogenesis of the disorder is unknown, but the lack of a dose-effect relationship, the rarity and unpredictability of the reaction, as well as the clinical signs suggest that hypersensitivity is involved. Physicians should be aware of this rare and idiosyncratic side-effect of ranitidine.

Intense 18-fluorodeoxyglucose uptake by the thymus on PET scan does not necessarily herald recurrence of thyroid carcinoma.

This is the first report of intense fluorodeoxyglucose positron emission tomography (FDGPET) uptake secondary to thymic hyperplasia during follow-up for thyroid carcinoma. A 36-yr-old woman underwent thyroidectomy for a papillary carcinoma measuring 4 cm in diameter. After two doses of radioiodine, thyroglobulin (Tg) remained detectable following recombinant human TSH (rhTSH) stimulation. A whole body scan (WBS) was negative. On computed tomography (CT) scan, a slightly lobulated thymus was visualized. PET scan showed intense thymic uptake. Following resection, anatomo-pathological analysis showed homogenous hyperplastic thymic gland without neoplastic cells. Two months later, under levothyroxin (L-T4) substitution, Tg was no longer detectable and PET scanning did not show any 18-FDG uptake. This observation suggests that thymic FDG uptake does not necessarily herald recurrence of thyroid carcinoma and must be interpreted with caution in such a setting. Other conditions associated with abnormal uptake by hyperplastic thymus must also be envisaged.