Nicole Berger

Predictive Factors for Recurrence from a Series of 74 Children and Adolescents with Differentiated Thyroid Cancer

The influence of clinical and treatment factors on the risk of recurrence was analyzed from a retrospective series of 74 children and adolescents with thyroid cancer (55 girls, 19 boys; age 2–20 years). Two groups, comparable in terms of age, sex, and previous radiotherapy, were compared according to the presence (group 1) or absence (group 2) of cervical lymph nodes identified by palpation or ultrasonography. Total thyroidectomy (TT) with lymph node dissection (LND) was performed in the 19 group 1 patients, whereas in group 2 patients (n = 55) lobectomy was performed in 29, TT in 26, and LND in 7. Pathology studies showed papillary thyroid carcinoma in 95% of cases. In group 1, tumors were more frequently multifocal (89% vs. 16% in group 2), invasive with extension beyond the thyroid capsule (68% vs. 5% in group 2), and of the diffuse sclerosing variety (63% vs. 4% in group 2) (p < 0.001). With a median follow-up of 61 months, lymph node recurrence was seen in 53% of group 1 patients and in no patients in group 2. Three group 2 patients (10%) were reoperated for a local recurrence after lobectomy. Risk factors for reintervention were young age (< 15 years) (p < 0.01) and cervical lymph nodes (p < 0.001). Survivals without reintervention at 5 and 10 years were, respectively, 58% and 38% for group 1 and 94% and 90% for group 2 (p < 0.001). At the time of analysis, 68% of group 1 patients and 98% of group 2 patients were in remission. In conclusion, the presence of palpable cervical lymph nodes at diagnosis is associated with more invasive forms of malignancy and is a predictive factor of recurrence regardless of the extent of the initial surgery.

Thyroid carcinomas with distant metastases: a review of 111 cases with emphasis on the prognostic significance of an insular component.

Distant metastases (DM) are rare in well-differentiated thyroid carcinomas and correlate with a poor survival. Among the histologic subtypes, insular carcinoma has an intermediate prognosis that lies between well and undifferentiated carcinomas. To assess the characteristics that could predict a worse prognosis, we reviewed the initial thyroid cancer slides from patients with DM. We achieved a comparative statistical analysis with a control group without DM. Among 1230 differentiated carcinomas treated from 1960 to 1999, 9% developed DM. In this group the mean age was 53 years, with a 73% rate of death. The histologic slides were available in 80 cases. The primary thyroid tumors were classified as papillary (51 cases), follicular (25), and pure insular carcinomas (4). Extrathyroidal extension was present in 47% of papillary carcinomas. The mean tumor size was above 5 cm for all the histologic subtypes, and at least a vascular invasion was found in 69%. Fifty-four percent of these tumors had an insular component compared with only 6.5% in the control group. The statistical analysis confirmed by univariate and multivariate logistic regression that the risk of DM was highly elevated in the presence of insular carcinoma. Our study indicates that elevated age, large tumor size, vascular invasion, and extrathyroidal extension are important prognostic factors in well-differentiated carcinomas. We also demonstrate that the presence of an insular component in an otherwise differentiated carcinoma is a strong independent poor prognostic factor.

Occult Micro Medullary Thyroid Carcinoma: Therapeutic Strategy and Follow-up

Twenty micro medullary thyroid carcinomas (MTCs) were found in histologic specimens of 19 patients in our department from 1990 to 1998. There were 14 women and 5 men, with a median age of 63 years. The indication for surgery was goiter in 12 patients and a solitary nodule in 7 patients (three differentiated cancers). Altogether, 18 patients had unifocal micro-MTCs with a median diameter of 3.6 mm. One patient had a bilateral MTC (3 and 5 mm, respectively). Surgical procedures consisted of 9 total thyroidectomies and 10 lobectomies or subtotal thyroidectomies. Of these 10 patients, 4 underwent reoperation (totalization). One was operated on 48 months after a positive pentagastrin test: There was no thyroid residual tumor but three lymph node micrometastases. Among the six patients in whom thyroid tissue was left, a 91-year-old woman died of unrelated cause and the five others remain disease-free without biologic abnormalities at follow-ups of 18 to 70 months. Considering the aggressiveness of MTCs, total thyroidectomy with central compartment dissection is theoretically indicated. However, among the nine total thyroidectomies and four secondary totalizations associated with at least central compartment dissection, no other thyroid lesion was observed and only one case of lymph node microinvasion was found. Because of the morbidity associated with reoperation and neck dissection, we propose that it is indicated only for microcarcinomas > 5 mm in diameter, in cases of an abnormal response to pentagastrin, or when it is difficult to ensure prolonged follow-up of the patient.

La localisation préopératoire des insulinomes est-elle utile ?

Study aim: To appreciate the impact of preoperative localization in surgical treatment of insulinomas. n nPatients and method: From 1986 to 2001, 29 patients were surgically treated for suspected insulinoma. Preoperative imaging assessment was performed in 26 patients : ultrasonography (n=21), computed tomography (n=23), endoscopic ultrasonography (n=13), intraoperative ultrasonography (n=22) (2 of them under laparoscopic approach). n nResults: The sensibility of the localization procedures was as follows: ultrasonography=9,6%, computed tomography=39%, endoscopic ultrasonography=92,3%, surgical exploration79,3%, intraoperative ultrasonography 86,3%. The sensibility of intraoperative palpation associated which intraoperative ultrasonography was 100%. Surgical procedures included: 11 enucleations, 10 segmental resections of the tail, 1 left pancreatectomy, 3 median pancreatectomies, 4 subtotal pancreatectomies. There was no postoperative mortality and postoperative morbidity rate was 17%, including 4 pancreatic leakages. Histological examination found solitary tumor in 22 patients (1 of them was a malignant tumor), multiple tumors (MEN 1) in 4 patients and facticious hypoglycemia in 3 patients. All the insulinomas were resected. n nConclusion: Intraoperative evaluation of the pancreas with intraoperative ultrasonography was associated which a right localization in 100% of insulinomas. The place for preoperative imaging seems to be limited. A laparoscopic approach in sporadic insulinomas could modify this attitude.Resume But de l’etudexa0: Apprecier l’interet de la localisation preoperatoire des lesions pour la prise en charge chirurgicale des insulinomes. Patients et methodexa0: De 1986 a 2001, 29 patients ont eu une exploration chirurgicale pour suspicion d’insulinome. Des examens d’imagerie preoperatoire ont ete realises chez 26 patientsxa0: echographie ( n =xa021), tomodensitometrie ( n =xa023), echoendoscopie ( n =xa013). L’exploration chirurgicale a ete couplee 22 fois a une echographie peroperatoire. Resultatsxa0: La sensibilite de l’echographie, de la tomodensitometrie et de l’echoendoscopie a ete respectivement de 9,6, 39 et 92,3xa0%. L’exploration chirurgicale a permis une localisation des lesions dans 79,3xa0% des cas. La sensibilite de l’echographie peroperatoire a ete de 86,3xa0%. L’exploration chirurgicale couplee a l’echographie peroperatoire (par laparotomie ou par laparoscopie) a permis un diagnostic lesionnel dans 100xa0% des cas. Les operations realisees ont etexa0: 11 enucleations, dix pancreatectomies caudales, une splenopancreatectomie gauche, trois pancreatectomies segmentaires medianes et quatre pancreatectomies subtotales. La mortalite operatoire a ete nulle et la morbidite de 17xa0%, avec quatre fistules pancreatiques. Il s’agissait de 22 insulinomes sporadiques uniques (dont un malin), de quatre NEM 1 et de trois hypoglycemies factices. Tous les patients ayant des lesions organiques ont ete gueris de leur endocrinopathie. Conclusionxa0: L’exploration chirurgicale avec echographie peroperatoire a permis un diagnostic lesionnel dans 100xa0% des cas, ce qui rend discutable l’utilite des examens morphologiques preoperatoires. Une prise en charge totalement laparoscopique des formes sporadiques pourrait modifier cette attitude.

Immunohistochemical markers in the diagnosis of papillary thyroid carcinomas: The promising role of combined immunostaining using HBME-1 and CD56.

We aimed to evaluate the expression and diagnostic value of five immunohistochemical markers (HBME-1, Galectin-3, CK19, CD56 and p63) in a very large series of unequivocal papillary thyroid carcinoma (PTC) cases, including both the classic (CPTC) and the follicular variant (FVPTC). We performed an immunohistochemical analysis on a tissue micro-array of 204 PTCs (98 CPTCs, 90 FVPTCs, and 16 other variants). HBME-1 was the most sensitive marker, staining 95.9% of CPTCs and 81.1% of FVPTCs. CD56, a marker whose expression is reduced or absent in thyroid carcinoma, revealed a negative, malignant profile in 93.9% of CPTCs and 73.3% of FVPTCs. Galectin-3, CK19 and p63 were positive in 64.7%, 45.6% and 6.9% of PTCs, respectively. The immunopanel consisting of HBME-1, CD56 and/or CK19 reached the highest sensitivity (95.6%). The co-expression of 2 or more proteins was observed in 88.2% of PTCs, with HBME-1 and CD56 being the most frequent positive association (79.4%). We report a new panel of antibodies consisting of HBME-1, CK19 and CD56 that was found to be highly sensitive for both CPTC and FVPTC. This panel could be recommended as a supplement to the morphological criteria in the diagnosis of difficult FVPTC cases.

Is basal ultrasensitive measurement of calcitonin capable of substituting for the pentagastrin‐stimulation test?

To evaluate a second‐generation assay for basal serum calcitonin (CT) measurements compared with the pentagastrin‐stimulation test for the diagnosis of inherited medullary thyroid carcinoma (MTC) and the follow‐up of patients with MTC after surgery. Recent American Thyroid Association recommendations suggest the use of basal CT alone to diagnose and assess follow‐up of MTC as the pentagastrin (Pg) test is unavailable in many countries.

Traitement actuel des phéochromocytomes: à propos de 50 cas.

Study aim. – The aim of this retrospective study was to assess our experience of the laparoscopic surgery of pheochromocytoma .We report indications and results of laparoscopic and open adrenalectomy for pheochromocytoma. n nPatients and methods. – Between january 1994 and may 2002, 50 patients underwent laparoscopic or open adrenalectomy for pheocromocytoma. The perioperative hemodynamic parameters were assessed for each patient. In each case, urinary metanephrine levels were measured at the second month postoperatively. The long term outcome was assessed in 44 patients. The mean follow-up was 39 months. n nResults. – Ten patients underwent open adrenalectomy: 8 patients for unilateral tumors (tumor size was > 8cm in 7 cases) and 2 patients for bilateral tumors (1 recurrence and 1 cystic polylobed tumor). Fourty patients underwent laparoscopic adrenalectomy: in 32 cases, including 1 patient with a bilateral tumor, no conversion was performed (tumor size was < 5cm in 29 cases). In 8 cases (20%), a conversion to an open operation was performed. The reasons to convert were bleeding and periadrenal fibrosis in 7 cases. In laparoscopic adrenalectomy group, hemodynamic troubles were not more frequent, the hospital stay was shorter and there was no recurrence. n nConclusion. – Laparoscopic adrenalectomy is the Gold standard procedure for patients with pheochromocytoma. But open adrenalectomy is sometimes indicated: tumor size > 8cm, periadrenal fibrosis, and recurrence tumor.Study aim. – The aim of this retrospective study was to assess our experience of the laparoscopic surgery of pheochromocytoma .We report indications and results of laparoscopic and open adrenalectomy for pheochromocytoma. n nPatients and methods. – Between january 1994 and may 2002, 50 patients underwent laparoscopic or open adrenalectomy for pheocromocytoma. The perioperative hemodynamic parameters were assessed for each patient. In each case, urinary metanephrine levels were measured at the second month postoperatively. The long term outcome was assessed in 44 patients. The mean follow-up was 39 months. n nResults. – Ten patients underwent open adrenalectomy: 8 patients for unilateral tumors (tumor size was > 8cm in 7 cases) and 2 patients for bilateral tumors (1 recurrence and 1 cystic polylobed tumor). Fourty patients underwent laparoscopic adrenalectomy: in 32 cases, including 1 patient with a bilateral tumor, no conversion was performed (tumor size was < 5cm in 29 cases). In 8 cases (20%), a conversion to an open operation was performed. The reasons to convert were bleeding and periadrenal fibrosis in 7 cases. In laparoscopic adrenalectomy group, hemodynamic troubles were not more frequent, the hospital stay was shorter and there was no recurrence. n nConclusion. – Laparoscopic adrenalectomy is the Gold standard procedure for patients with pheochromocytoma. But open adrenalectomy is sometimes indicated: tumor size > 8cm, periadrenal fibrosis, and recurrence tumor.

Corticosurrénalome malin : facteurs pronostiques des récidives locorégionales et indications des réinterventions. À propos d’une série de 22 patients

Resume But de l’etudexa0: Les buts de notre etude retrospective etaient d’evaluer les facteurs pronostiques de recidive locoregionale chez les patients operes d’un corticosurrenalome malin et d’evaluer l’interet des reinterventions. Materiel et methodexa0: De 1985 a 2001, 22 patients ont ete operes d’un corticosurrenalome malin. Nous avons etudie l’influence sur la survie sans recidive locoregionale du stade tumoral, du nombre de criteres de Weiss, de l’index mitotique, de l’exerese elargie aux organes de voisinage et du traitement par Op’DDD. Puis nous avons evalue l’interet des reinterventions. Resultatsxa0: Sept patients ont eu une recidive locoregionale apres un recul median de 25 mois et le taux de survie actuarielle sans recidive locoregionale a cinq ans etait de 50xa0%. Les patients dont la tumeur etait de stade I ou II, dont le nombre de criteres de Weiss etait ⩽xa06 ou dont l’index mitotique etaient ⩽xa020 mitoses/50 HPF avaient statistiquement une survie sans recidive locoregionale prolongee. L’exerese elargie aux organes de voisinage semblait diminuer le risque de recidive locoregionale. L’Op’DDD n’avait pas d’influence. Quatre patients ont eu une exerese iterativexa0: deux sont vivants sans recidive 54 et 8 mois apres la reintervention et deux sont decedes, 19 et 25 mois apres la reintervention. Trois patients n’ont pas eu d’exerese iterative. Ils sont decedes dans les huit mois. Conclusionxa0: Outre la moindre agressivite tumorale intrinseque (tumeurs de stade I et II, index mitotique faible), une meilleure prevention des recidives locoregionales peut reposer sur une exerese etendue en monobloc aux organes de voisinage. Les reinterventions peuvent prolonger la survie en cas d’exerese complete de la recidive. L’Op’DDD n’a pas fait la preuve de son efficacite.

Les opérations pour hyperparathyroïdie primaire en 1998.À propos de 66 patients et de trois voies d’abord

Resume But de l’etudexa0: Le but de cette etude prospective etait d’evaluer les benefices et les contraintes de la cervicotomie, de l’abord electif et de la videochirurgie dans le traitement de l’hyperparathyroidie primaire (HPT 1). Patients et methodesxa0: Au cours de l’annee 1998, 66 patients ont ete operes pour HPT 1 dans le meme centre. Il s’agissait de 48 femmes et 18 hommes (âge moyenxa0: 58 ans, extremesxa0: 21–84). Aucun n’avait de forme familiale ou de neoplasie endocrinienne multiple. L’intervention a ete realisee par cervicotomie ( n xa0: 32), par abord electif lateralise ( n xa0=xa08), par videochirurgie ( n xa0=xa025). Un adenome mediastinal a ete enleve par cervicotomie et un autre par thoracoscopie gauche. Le dosage rapide de la parathormone (PTH) etait effectue 20xa0minutes apres exerese de l’adenome. La calcemie etait dosee a la 24 e et 48 e heure et deux mois apres l’intervention. Resultatsxa0: L’examen anatomopathologique a trouve un adenome double et 65 adenomes uniques. L’exerese a ete suivie dans tous les cas d’une chute significative de la PTH. Dans le groupe traite par chirurgie video-assistee, il y a eu 11 conversions en cervicotomie (44xa0%) et une paralysie recurrentielle. A la fin de l’etude, tous les patients sauf un etaient normocalcemiques. Conclusionxa0: Ce travail confirme la faisabilite de la chirurgie video-assistee dans l’hyperparathyroidie. Elle necessite un reperage preoperatoire de l’adenome et un dosage rapide peroperatoire de la PTH. Elle permet de reduire la taille de la cicatrice et evite la sternotomie pour l’exerese des adenomes mediastinaux. L’abord electif a un interet comparable a celui de la videochirurgie et une plus grande simplicite. La cervicotomie conserve une place de choix en cas de cervicotomie anterieurement, de thyroidectomie associee, de non reperage de l’adenome par l’imagerie et chez les sujets âges moins concernes par des preoccupations esthetiques.

Hyperparathyroidies primaires juveniles. A propos de 24 observations

Aim of the study: Primary hyperparathyroidism usually affects elderly patients. Juvenile primary hyperparathyroidism is rare, and raises diagnostic and pronostic problems. The aim of this retrospective study on 24 patients is to establish clinical, histological, and therapeutic features of juvenile primary hyperparathyroidism. n nPatients and methods: From 1986 to 2001, 673 patients were treated for primary hyperparathyroidism in our department. Twenty four patients were younger than 30 years old (3,5%). There were 14 women and 10 men. Mean age was 23 year (14–30). Clinical manifestations, pathologics findings and postoperative results were studied. n nResults: Sixteen patients presented a sporadic form of primary hyperparathyroidism with a single adenoma. Clinical manifestations were renal symptoms in 11 cases and acute hypercalcemia syndrome in 2 cases. Seven patients had a NEM I syndrome: parathyroid lesions were 6 hyperplasia and one adenoma. A 27 years old woman presented a recurrent familial isolated hyperparathyroidism. She was operated on 10 years before and at reoperation parathyroid carcinoma was found. Nineteen patients were cured after a post operative follow up ranging from 3 to 168 months. One patient had an asymptomatic hypercalcemia recurrence. Two patients presented permanent hypoparathyroidism treated whith calcitriol and calcium. n nConclusion: Sporadic forms represent majority of cases of juvenile hyperparathyroidism. Renal manifestations are usual. Nevertheless, multiple endocrine neoplasia type 1 has to be evocated.