Léopold Pirson (a), Yves Humblet (b), Ingrid Ferreira de Castro Moutinho (c), Christine Galant (c), Dominique Maiter (d)Published in the journal : March 2017Category : Oncologie
Numerous cases of Krukenberg tumors have been described in the literature, with several reviews on this topic published over these last three decades. The precise origin of these metastatic tumors is often unknown, in spite of the availability of biological and immunohistochemical markers. This case-report sought to present the diagnostic and therapeutic challenges raised by Krukenberg tumours in the course of a poorly-differentiated adenocarcinoma of atypical presentation, along with a review of the literature on this topic. We report the case of a 29-year-old patient referred to the endocrinology department for increased bone turn-over and elevated parathormone levels, in the context of chronic lower back pain. Further examinations revealed bilateral Krukenberg tumors, multifocal osteoblastic bone metastases, as well as probable peritoneal dissemination. While the primary origin of the metastases is still unknown, they are likely of gastro-intestinal origin, following careful exclusion of breast carcinoma. Whereas there are no guidelines on the management of Krukenberg tumors, actual therapy primarily consists of bi- or tri-chemotherapy with bilateral adnexectomy, leading to extended survival from a few months to several years. Yet prognosis remains poor with a median survival time of only 16 months, unless both primary tumor and metastases can be fully resected, with then considerably extended survival.
Dan Putineanu, Thomas SchubertPublished in the journal : March 2017Category : Diabétologie
As part of the multidisciplinary management of the diabetic foot, surgery plays a key role in the prevention and control of infection, in bone and soft tissue reconstruction, in limb preservation, and in the execution of amputation meant to be as distal as possible while offering a correct amputation stump. To achieve these objectives, plenty of surgical techniques are currently available.
Duplex sonography is still regarded as the first-choice imaging technique for the work-up of diabetic patients with suspected peripheral artery disease. Should additional information be required prior to digital subtraction angiography (DSA), computed tomography angiography (CTA) or magnetic resonance angiography (MRA) can be performed. The article has outlined in a comprehensive manner both the advantages and shortcomings of these techniques. DSA, an invasive technique, is still considered the gold standard, offering the highest spatial resolution and image quality, in addition to the possibility of performing endovascular revascularization of the limb within the same session.
Laura Orioli, Bernard VandeleenePublished in the journal : March 2017Category : Diabétologie
The ulcer of the foot is a complication occurring in 20% of diabetic patients. Diabetic neuropathy is the primary cause, with infection and arteritis profoundly influencing its management and prognosis. Evaluation should be systematically conducted using the PEDIS classification. The evaluation and management of the diabetic foot ulcer require a multidisciplinary and interprofessional medical and paramedical team. The dialogue between the different lines of care, along with the respect of their respective roles, proves equally crucial. Therefore, deep and extensive infection, Charcot foot, and severe arteritis all require patient management in a reference center.
Multiple factors may account for the chronic toxicity of synthetic glucocorticoids (GCs), which are (too) widely prescribed in clinical practice. The relative potency of the GCs used, daily dose administered, duration of treatment, route and time of administration, as well as individual factors like age, genetic factors, or significant co-morbidity, such as renal or hepatic failure, determine the delay in the occurrence of potentially serious complications, including the suppression of the corticotropic axis. The concomitant use of drugs affecting the metabolism and/or the action of these glucocorticoids must also be considered. While the selected treatment strategy should take into account all these factors, it must also consider the desired effects and proofs of efficacy. Whenever possible, short-term treatment or non-systemic administration of glucocorticoids should be preferred. Iatrogenic Cushing's syndrome is characterized by specific complications, including posterior subcapsular cataract, benign intracranial hypertension, osteonecrosis of the femoral and humeral heads, tendon ruptures, pancreatitis or psychotic crisis. Suppression of the hypothalamus-pituitary-adrenal (HPA) axis can be assumed in patients receiving over 16mg of methylprednisolone per day (or equivalent dose) for at least 6 weeks and in those exhibiting clinical Cushing’s syndrome. On the contrary, this condition is rather unlikely in patients receiving nonparenteral corticosteroids for less than 3 weeks. In other situations, adrenal function must be assessed before considering glucocorticoid withdrawal. This comprises the measurement of morning plasma cortisol levels, in addition to a short corticotropin (ACTH) stimulation test. If the results confirm either complete or partial suppression of the HPA axis, treatment with hydrocortisone (20mg/day in the morning) should be administered until recovery of adrenocortical function.
Recent studies have demonstrated that most genetically-determined adrenal lesions responsible for Cushing's syndrome display abnormal cell differentiation resulting in the development of paracrine regulation loops that favor cortisol hypersecretion. In bilateral adrenal macronodular hyperplasia tissues, the causative gene mutations appear to lead to pseudo-gonadal differentiation of a subpopulation of adrenocortical cells, resulting in aberrant ACTH synthesis. In primary pigmented adrenocortical disease (PPNAD) and in some cortisol-secreting adenomas, activation of the protein kinase A (PKA) pathway is directly responsible for upregulation of the serotonergic signaling pathway . These original observations provide new insights into the pathophysiology of primary adrenal Cushing's syndrome. They also suggest that illicit intraadrenal paracrine regulatory mechanisms may be regarded as valuable targets for new pharmacological treatments of hypercortisolism. These original therapeutic approaches could represent valuable alternatives to adrenal surgery and the currently used anticortisolic drugs which are responsible for various side-effects.
The occurrence of early pubic hair often causes concern to both families and physicians. Whereas, in the majority of cases, this is only a normal variant called premature adrenarche, this condition may also be related to potentially serious diseases, such as congenital adrenal hyperplasia, adrenal tumors, or gonadal tumors, which must be correctly diagnosed and managed appropriately.
Assessing cortisol levels is recommended in the event of suspected hypercorticism like Cushing's syndrome, as well as in the event of hypocorticism like adrenal insufficiency. Cortisol testing is therefore a major tool for clinicians, and especially for endocrinologists, with particular attention required for selecting the most appropriate cortisol measurement tool in relation to clinical expectations. Most of the current assays while being automated rely on immunoassays. It should, however, be noted that the standardization process for cortisol assays has not yet been fully completed, with still significant inter-method variations. The clinicobiological relationship thus appears paramount in order to best select the most appropriate cortisol assessment method.
The IQON spectral CT scanner manufactured by Philips Healthcare has been installed at the beginning of May 2016 in our department of radiology. The CT scanner is performing all types of examinations but is more dedicated to patients referred from the emergency unit. We are performing an average of 40 patients per day with approximately half of them coming directly from the emergency room. After a few months of use, this machine with a 4 cm coverage, rotation time of 0.27 sec and spectral data analysis “on demand” appears especially designed for emergency cases and will definitely change our work-up of such patients where CT constitutes the front line examination with a major role in patient triage. The Spectral Diagnostic Suite is designed to display the spectral data very rapidly after the CT acquisition. The radiologist is able to load the images and analyze the spectral data within 2-3 minutes. In the scenario of emergency situations, some characteristics of the spectral CT seem very promising. The aim of this article is to share with you our preliminary experience of the IQON CT and highlight the applications which seem to be the most useful in the emergency situations.
Monique Decat, Gersende Debie, Naima Deggouj, Anaïs GregoirePublished in the journal : February 2017Category : Otologie
The management of hearing-impaired patients has taken a leap forward with the reimbursement of partially-implantable middle ear implants. Formerly, patients with neurosensory hearing loss (i.e., related to the destruction of the inner ear) could only benefit from hearing aids or cochlear implants provided they were totally deaf. Most of them were not satisfied with their hearing aids. Partially- or even fully-implantable middle ear implants were already available, but their costs were fully borne by the patient (between 10,000 and 18,000 euros approximately).