L. Leenhardt

Guidelines of the French society of endocrinology for the management of thyroid nodules

The present document is a follow-up of the clinical practice guidelines of the French Society of Endocrinology, which were established for the use of its members and made available to scientific communities and physicians. Based on a critical analysis of data from the literature, consensuses and guidelines that have already been published internationally, it constitutes an update of the report on the diagnostic management of thyroid nodules that was proposed in France, in 1995, under the auspices of the French National Agency for Medical Evaluation (lAgence nationale dévaluation médicale). The current guidelines were deliberated beforehand by a number of physicians that are recognised for their expertise on the subject, coming from the specialities of endocrinology (the French Thyroid Research Group) and surgery (the French Association for Endocrine Surgery), as well as representatives from the fields of biology, ultrasonography, cytology and nuclear medicine. The guidelines were presented and submitted for the opinion of the members of the Society at its annual conference, which was held in Nice from 7-10xa0Octoberxa02009. The amended document was posted on the website of the Society and benefited from additional remarks of its members. The final version that is presented here was not subjected to methodological validation. It does not claim to be universal in its scope and will need to be revised in concert with progress made in technical and developmental concepts. It constitutes a document that the Society deems useful for distribution concerning the management of thyroid nodules, which is current, efficient and cost effective.

Surgical management of sporadic medullary thyroid cancer

Inherited and sporadic medullary thyroid cancer (MTC) is a rare carcinoma. Sporadic MTCs represent 70% of cases. Diagnosis is currently made with the routine use of serum calcitonin (CT) measurements to screen patients with nodular thyroid disease. Surgery is the only curative treatment of MTC and since cervical lymph nodes metastases are frequent and can occur at an early stage, a standardized lymph node dissection should be associated to total thyroidectomy. However, the extent of lymphadenectomy remains debated. Prognosis of MTC is related to both the stage of the disease and the extent of initial surgery. When tumor remnants persist after surgery, there are very few therapeutic alternatives, and these are generally of limited curative value.

Is Thyroid Cancer Recurrence Risk Increased After Transplantation

CONTEXTnAn increased cancer mortality is reported in transplanted patients.nnnOBJECTIVEnThis multicentric study aimed to investigate the rate of thyroid cancer recurrence after transplantation.nnnRESULTSnSixty-eight patients (35 male/33 female) with a history of both thyroid cancer and organ transplantation were recruited via two nationwide French networks. Histological analysis identified 58 papillary (88%), 5 follicular (7.5%), and 3 poorly differentiated cancer cases (4.5 %). Thirty-one patients (52%) presented high recurrence risk tumors. In the 36 patients with thyroid cancer diagnosed after transplantation, the 5-year disease-free survival (DFS) was 74.7% (SE: 7.3%). One patient died after progression of a poorly differentiated cancer. Persistent disease was observed in six high-risk patients. One of them underwent a second transplantation and disease remained stable after 5 years of follow-up. Thyroid cancer had been diagnosed before transplantation in 32 patients. One patient with cystic fibrosis and thyroid lung metastases at the time of lung transplantation underwent a 4-year remission. For the 31 patients in remission at the time of transplantation, the 5-year DFS was 93.1% (SE: 4.8%). Two patients with local recurrence presented subsequent remission. For the entire study population, the 5-year and 9-year DFS were 81.9% (SE: 5.5%) and 75.6% (SE: 7.9%), respectively. Recurrence or persistent disease occurred in patients with high-risk tumors.nnnCONCLUSIONSnThe prognosis of thyroid cancer does not seem to be altered by transplantation. This suggests that a history of thyroid cancer should not be considered a contraindication.

Transcutaneous Laryngeal Ultrasonography for Laryngeal Immobility Diagnosis in Patients with Voice Disorders After Thyroid/Parathyroid Surgery

AbstractBackgroundTranscutaneous laryngeal ultrasonography (TLUS) was recently developed to assess recurrent nerve palsy after thyroid/parathyroid surgery, with variable rates of efficiency. The aim of the current study was to evaluate this technique using subjective estimation and post-processing quantitative data.nMethodsFifty subjects presenting with a recurrent nerve palsy and 50 “controls” presenting with voice, swallowing, or breathing disorders following thyroid/parathyroid surgery were prospectively included. All of them underwent a flexible laryngoscopy, considered the gold standard, and a ten-second TLUS clip within the 10xa0days following surgery. In addition to the subjective interpretation of vocal fold motion, two quantitative criteria taking into account motion symmetry (symmetry index, SI) and amplitude (mobility index) of the two hemi-larynges were defined on TLUS acquisitions in adduction and abduction.nResultsThe subjective interpretation provided a sensitivity of 100% and a specificity of 96%, compared to the gold standard. The quantitative criteria provided a sensitivity and specificity of both 82%, when based on SI solely. When combining SI and mobility index, the sensitivity reached 94%, but the specificity fell to 66%.ConclusionsVisual assessment of recurrent nerve palsy using TLUS after thyroid/parathyroid surgery appeared a high sensitive and specific test compared to flexible laryngoscopy. Quantitative criteria are promising and need to be refined to better describe the whole TLUS video clip.

Quantification of vocal fold motion using echography: application to recurrent nerve paralysis detection

Recurrent nerve paralysis (RP) is one of the most frequent complications of thyroid surgery. It reduces vocal fold mobility. Nasal endoscopy, a mini-invasive procedure, is the conventional way to detect RP. We suggest a new approach based on laryngeal ultrasound and a specific data analysis was designed to help with the automated detection of RP. Ten subjects were enrolled for this feasibility study: four controls, three patients with RP and three patients without RP according to nasal endoscopy. The ultrasound protocol was based on a ten seconds B-mode acquisition in a coronal plane during normal breathing. Image processing included three steps: 1) automated detection of two consecutive closing and opening images, corresponding to extreme positions of vocal folds in the sequence of B-mode images, using principal component analysis of the image sequence; 2) positioning of three landmarks and robust tracking of these points using a multi-pyramidal refined optical flow approach; 3) estimation of quantitative parameters indicating left and right fractions of mobility, and motion symmetry. Results provided by automated image processing were compared to those obtained by an expert. Detection of extreme images was accurate; tracking of landmarks was reliable in 80% of cases. Motion symmetry indices showed similar values for controls and patients without RP. Fraction of mobility was reduced in cases of RP. Thus, our CAD system helped in the detection of RP. Laryngeal ultrasound combined with appropriate image processing helped in the diagnosis of recurrent nerve paralysis and could be proposed as a first–line method.

Risk of recurrence in a homogeneously managed pT3-differentiated thyroid carcinoma population

BackgroundInternational guidelines for the management of differentiated thyroid cancers are based on the 7th TNM classification: pT3 tumors are defined as differentiated thyroid cancers (DTCs) measuring more than 4xa0cm in their greatest dimension that are limited to the thyroid or any tumor with minimal extrathyroidal extension (ETE; sternothyroid muscle or perithyroid soft tissues). Differences in clinicohistological features and prognosis among patients with pT3 tumors remain controversial, and studies regarding pT3 subgroups are lacking.ObjectiveTo analyze the prognosis of four subgroups of pT3 DTCs (papillary, PTC; or follicular, FTC).Design and settingThe data of patients who underwent surgery for pT3 DTC between 1978 and 2015 in a surgical department specialized in endocrine surgery were reviewed. Patients were classified into four groups as follows: the pT3a (≤u200910xa0mm with ETE), pT3b (10–40xa0mm with ETE), pT3c (>u200940xa0mm without ETE), and pT3d groups (>u200940xa0mm with ETE). Recurrence-free survival (RFS) was analyzed using the Kaplan-Meier method.ResultsOne thousand eighty-eight patients with pT3 DTC were included, of whom 311 (29%) had pT3a; 548 (50%), pT3b; 165 (15%), pT3c; and 64 (6%), pT3d. For the 916 patients with lymph node (LN) dissection, metastatic LNs were more frequent in the pT3b and pT3d groups (61 and 61%, respectively) than in the other groups (44% pT3a and 10% pT3c; pu2009<u20090.001). During the median follow-up period of 9xa0years (range, 2–38xa0years), recurrence occurred in 169 patients with T3 tumors (16%), including 18 with pT3a (6%), 100 with pT3b (18%), 20 with pT3c (12%), and 31 with pT3d (48%). In a multivariate analysis, LN metastases (<u20090.0001), extranodal extension (pu2009=u20090.03), FTC (vs. PTC) (pu2009=u20090.006), pT3b (pu2009=u20090.016), and pT3d (pu2009=u20090.047) were associated with an increased risk of recurrence. The 5-year RFS rates were 94.5, 82.2, 91.1, and 50.3% for the pT3a, pT3b, pT3c, and pT3d groups, respectively (pu2009<u20090.01).ConclusionExcept for microcarcinoma, the risk of LN involvement is high and similar for the DTC patients with minimal ETE, regardless of the size of the tumor. The association of a tumor size of >u20094xa0cm and ETE are associated with a poor prognosis and should justify the classification of these cases as a high-risk group. Other pT3 patients with no LN metastases could be individualized as a low-risk group.

Questioning the pathogenic role of the pTyr791Phe mutation of the RET proto-oncogene: Insight from a case report.

UNLABELLEDnThe pTyr791Phe mutation of the RET proto-oncogene is associated with a low penetrance of medullar thyroid carcinoma (MTC). Thus, there is a lack in guidelines on management of these patients presenting without a thyroid disease.nnnCLINICAL CASEnA 27-year-old woman presented with a history of severe hypertension, paroxysmal tachycardia, diaphoresis and headaches. Twenty-four-hour urinary norepinephrine and normetanephrine levels were exclusively up to 20 times the normal limit. CT-scan and MRI found a 35-mm diameter right adrenal tumor, highly intense in T2- and hypo-intense in T1-weighted image, enhanced after gadolinium injection. After alpha-adrenergic blocker treatment, a surgical resection of the tumor was performed; this latter proved to be a pheochromocytoma. Genetic screening only revealed a germline pTyr791Phe mutation of the RET proto-oncogene. However, the patient showed no evidence of MEN2: basal calcitonin was normal and calcium infusion test was negative. Thyroid ultrasound revealed a TIRADS 3 nodule with benign cytology. Total thyroidectomy was suggested but withheld due to the patients refusal and a close follow-up was decided.nnnCONCLUSIONnThis rare case of pTyr791Phe mutation-related pheochromocytoma without evidence of MTC questions the indication for prophylactic thyroidectomy in mutation carriers, as recent data challenges its pathogenicity.

Multiples échanges plasmatiques nécessaires chez une patiente présentant une maladie de Basedow sévère

Introduction Le traitement de reference de la maladie de Basedow repose sur les antithyroidiens de synthese (ATS). Le recours aux echanges plasmatiques est rare, et se fait en cas d’effet secondaire grave des ATS, de necessite de normaliser rapidement les hormones thyroidiennes, ou d’ophtalmopathie severe. Il existe peu de donnees sur l’efficacite d’un tel traitement. Observation Une patiente de 35xa0ans, ayant fait 3 poussees de maladie de Basedow depuis 2002, a presente une recidive en aout 2013, caracterisee par sa severite biologiquexa0: TSH indosable, T 3 libre superieure a 50xa0pmol/L, T4 libre superieure a 100xa0pmol/L. Les TRAK etaient fortement positifs a plus de 40xa0UI/L. Le traitement initialement introduit, le carbimazole (60xa0mg/j), est interrompu au bout de 10xa0jours pour neutropenie et remplace par du propylthiouracyl (PTU) (500xa0mg/j) associe a une corticotherapie (prednisone 0,7xa0mg/kg). L’inefficacite des antithyroidiens de synthese a conduit a realiser des plasmaphereses. Cinq seances seront necessaires pour diminuer suffisamment les taux de T3 et T4 libres et permettre la thyroidectomie totale. Discussion Cette patiente, traitee de facon efficace par ATS lors de ses poussees precedentes de maladie de Basedow, a presente de facon surprenante une resistance au carbimazole puis au PTU. Il est exceptionnel qu’autant de seances de plasmapherese soient necessaires pour diminuer les taux d’hormones thyroidiennes probablement lie chez notre patiente au volume important du goitre (142xa0g). Des recommandations therapeutiques seraient necessaires pour permettre leur utilisation dans la prise en charge de la maladie de Basedow.