Place de l’imagerie dans l’évaluation de l’efficacité des traitements dans le cancer du sein

This paper describes, from the current literature, the role of various imaging methods to assess the response to therapy in breast cancer. Two different clinical situations are considered: neoadjuvant chemotherapy of locally advanced breast cancer and the metastastic breast cancer. Significant clinical data are available for three criteria: the volume of the tumour, the uptake of fluorodeoxyglucose using PET and the perfusion of the tumor evaluated either by dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) or by PET using ¹⁵O water. ¹⁸F FDG PET allows prediction of the response after one or two cycles of neoadjuvant chemotherapy. New approaches will offer opportunities to refine the role of imaging in monitoring the response to chemotherapy. PET using thymidine as biomarker is promising in assessing the tissular proliferation. Estrogen analogs could be used to predict hormonally responsive breast cancer. Many other approaches, although less developed, might offer new insights in the response to therapy of breast cancer like magnetic resonance spectroscopy or optical imaging of hemoglobin oxygenation. Imaging also offers potential of monitoring the down-regulation of specialized receptors of the cell membrane in response to treatment: the most studied receptor in preclinical model has been the human epidermal growth factor receptor type 2 (HER2). Integrin, a family of cell adhesion receptor, is also an important target for imaging. Apoptosis, multidrug resistance and hypoxia can also be studied using appropriate biomarkers. To allow reliable multicenter trials of new drugs, these different imaging approaches still require an improved standardization of image acquisition and processing.     

Intérêt de l’imagerie hybride TEMP-TDM dans l’exploration des infections

Single-Photon Emission Computed Tomography-Computerized Tomography (SPECT-CT) is a new hybrid technique which offers new diagnostical capabilities in daily nuclear medicine practice. This technique not only allows to acquire fusioned anatomic and functional images in the same time, but also, it increases sensitivity and accuracy of SPECT thanks to attenuation and scattering corrections got from transmission data. Until now, SPECT-CT data have been mainly obtained in oncology and cardiology, but now, many authors use it in many scan studies and particularly for infectious diseases. In inflammatory bowel diseases, SPECT-CT seems to increase diagnostical performances and to modify management of many patients. In suspected vascular sepsis, SPECT-CT could increase sensitivity of white blood cell scintigraphy but also its specificity thanks to spatial resolution of CT. In osteoarticular sepsis, SPECT-CT has the advantage to distinguish osteomyelitis from soft tissue infection and to guide biopsies. Nevertheless, in the light of PET-CT works, SPECT-CT development will probably modify nuclear medicine practice and many studies have to be conducted to highlight consensual procedure guidelines.     

Apport de l’exploration cytogénétique et ultrastructurale dans le pronostic de fertilité des sujets globozoospermiques

Globozoospermia is a severe form of teratozoospermia characterized by round-headed sperms with absence or presence of a rudimentary acrosome. The objective of this study is to analyze sperm from six patients with globozoospermia syndrome and report the results of 11 intracytoplasmic sperm injection (ICSI) attempts. The investigation of these issues was carried out by studying the sperm aneuploidy rate by fluorescent in situ hybridization (sperm-FISH) for chromosomes X, Yand 18. The rate of DNA fragmentation was studied by using the terminal deoxynucleotidyl transferase dUTP nick end labelling (TUNEL) technique and a detailed ultrastructural morphology study of the sperm using transmission electron microscopy. Eleven ICSI attempts were performed in patients with low fertilization rate, (9.37%) and pregnancy did not occur. This study confirmed the variability of sperm phenotypes observed in this syndrome and the low fertilization rates after IVF-ICSI regardless of the phenotype.     

Le mammouth dans l’art paléolithique

The mammoth, an emblematic animal of the Prehistory, possesses an important place in the depictions made by prehistoric artists, both in parietal art (cave art) and in mobile art. Its image is known from the Aurignacian, at the beginning of the Upper Palaeolithic, until the end of the Last Ice Age, the Magdalenian. However, its geographical and chronological distribution is dissimilar. Mammoth depictions are generally more frequent during the Aurignacian where this animal is found engraved and painted in the Chauvet cave for example and carved from ivory in several cave sites of the Swabian Jura. The Magdalenian cave of Rouffignac and its 160 representations constitute a notable exception. From a formal point of view, the representations of mammoth are elaborated in a rather constant way, like the characteristic cephalic contour and the typical back of the animal, at least as it could be seen in nature. The representations are often even limited to a cursive line with a double curvature that expresses the pachyderm. On the other hand some drawings show intimate details. Sometimes the tusks of the mammoths are not indicated, but certain stylistic features, such as the ventral arch, are relatively reliable chronological markers. Finally, one cannot ignore the ethological or seasonal expressions that sometimes link the mammoths to each other, in a row or in confrontation. This animal obviously inspired the artists of the prehistory who created various portraits of the mammoth.     

Place du scanner dans l’imagerie de l’hyperparathyroïdie primaire

Primary hyperparathyroidism is a biological diagnosis. The reference treatment is surgery. When minimally invasive surgery is considered, it is recommended to perform a cervical ultrasound and a scintigraphic examination to localize the hypertrophied parathyroid glands. The multiphasic scanner (4D CT) is a very effective examination to detect and locate precisely the parathyroid adenomas. The study of densities makes it possible to differentiate the adenoma from the thyroid and the lymph nodes that are the differential diagnoses. Without injection, the adenoma is more hypodense than the thyroid with a threshold set at 75 UH. On the early phase after injection, the adenoma appears very hypervascularized with a density > 114 UH. The ganglion appears hypovascularized with a density < 114 UH. In the late phase, there is a decrease in the density within the adenoma, while density within the ganglion increases. The parathyroid scan is indicated in case of negativity or discordance of the couple ultrasound scintigraphy. It is also strongly recommended, in case of persistence or recurrence of hyperparathyroidism after surgery, as well as to better study a parathyroid ectopy.     

Apport de l’iode 131 dans le traitement de l’adénome thyroïdien toxique

IntroductionToxic thyroid adenoma is an evolutive condition requiring radical treatment. The purpose of this study is to evaluate the contribution of 131 in the treatment of toxic thyroid adenoma.Patients and methodsThis is a retrospective study of patients treated with iodine 131 for toxic thyroid adenoma. The diagnosis of toxic adenoma is confirmed by scintigraphy and/or ultrasound. Data collected were age, sex, previous treatments, pre treatment hormonal status, radioiodine activity received and post therapy hormonal status.Results and conclusionWe have 45 women to seven men with a sex ratio of 6.42. Mean age of our patients is 53 years. Mean age for women at time of treatment is 57.33 years and 52.85 years for men. 98.07% of our patients treated with iodine 131 gained euthyroidism or became hypothyroid vs. 1.92% in whom hyperthyroidism persisted. These results are comparable to literature. Moroccan patients socioeconomic status pleads for an expansion of use of radioiodine in toxic thyroid adenoma due to its favourable cost/effectiveness ratio.     

Apport de l’iode 131 dans le traitement de la maladie de Basedow dans le service de médecine nucléaire de l’hôpital Ibn Sina de Rabat

One hundred and twenty-nine Grave's Basedow diseases in any gender and variable age patients, coming from several cities of Morocco, were randomized in a study of radio-iodine treatment who took place at the nuclear medicine department of Ibn Sina Hospital (Rabat, Morocco) during the period (from January 2001 to December 2008). The radio-iodine treatment was a first, second or third option and radio-iodine activities delivered varied (from 222 to 555 MBq 6 to 15 mCi) according to the age, the thyroid volume, the degree of hyperthyroidism and socio-economical situation. The high amounts of ¹³¹I were reserved especially to the patients who live far and whose socio-economic level is low with an aim of quickly obtaining an easily controllable state of hypothyroidism by a substitute treatment. The results showed that: (1) 57.36% of patients reverted to euthyroïdism (n = 74) with a patient having received two ¹³¹I cures. The second cure was justified by recurrence of hyperthyroidism after the first cure; (2) 34.88% passed in hypothyroidism (n = 45) with three patients having received two cures of ¹³¹I, the second cure was justified by recurrence of hyperthyroidism after the first cure in two patients and by the persistence of the hyperthyroidism after the first cure for the third patient. The average time of passage in hypothyroidism was 4.5 months; (3) 7.76% had remained in hyperthyroidism after the radioactive iodine treatment. Finally, 92.24% of our patients treated by radioactive iodine had passed in euthyroïdism or hypothyroidism against 7.76% whose hyperthyroidism had persisted or occurred.     

Personnages dans l’art saharien : le réel et l’imaginé

In the Sahara, wherever there are naked rock surfaces, engravings and paintings have been found in large numbers. This rock art includes various types of images — the oldest dating about ten millenniums — among which human beings, wild or domesticated animals, therianthrops and non-explicit images can be identified. According to periods and styles, the human being has been represented under extremely varied aspects from particularly realistic — similar to the reality — till very simplified, even caricatural drawings. For some realistic representations of women and men, we can observe anatomical or morphological peculiarities which, without being frequent, show cases of steatopygy and gynoïd or androïd obesity, pathological or not. For certain periods, we also find imaginary, fantastic or caricatural representations. These images characterize particularly styles previous to that called “Round Heads”. So, in the Saharan art, the human being has been represented either in his physical truth, or according to multiple stylistic conventions or graphic stereotypes, which could characterize certain ethnic groups.     

Indications de l’imagerie dans l’infertilité masculine (bourses,testicules)

Imaging modalities in the work up of male infertility are almost resumed to Ultrasound with Color Doppler which is quite performant if its indications are well-balanced:

-To look for abnormalities of the seminal tract.

-To evaluate clinical varicoceles (Testis, associated abnormalities).

-To screen the neoscrotal pouchs of ectopic operatively corrected Testis (occult tumor, epididymal abnormalities).

     

Impact de l’imagerie hybride TEMP/TDM dans le diagnostic et la prise en charge de l’ostéome ostéoïde

IntroductionThe osteoid osteoma is a major bone benign tumors in children. It is more common in boys. The femoral and tibial locations account for 50% of cases. Clinically, it is revealed by nocturnal pain relieved by aspirin. The pain may precede by several months the radiographic abnormality. The purpose of our work is to elucidate the contribution of SPECT/CT in addition to the planar bone scintigraphy in the diagnosis and treatment of osteoid osteoma about two cases.Case reportClinical case No. 1: a 10-year-old child who presented a limp nocturnal pain in the left hip evolving for 4 months. The radiograph of the pelvis showed bone condensation subtrochanteric left femur. SPECT/CT showed an image for an osteoid osteoma. Surgical resection of the home revealed in the histological study an osteoid osteoma of the left femoral neck. The evolution was marked by an immediate pain relief and full recovery of the left lower limb mobility. Clinical case No. 2: an 11-year-old child who had a limp nocturnal pain at the upper end of the left femur evolving for 2 months. The pain was paroxysmal, relieved by salicylates. The X-ray of the pelvis showed a metaphyseal image with peripheral condensation and thickening of the cortex. SPECT/CT showed an image for an osteoid osteoma. The intervention was a tumor excision resection. Histopathological examination revealed a small nidus consistent with an osteoid osteoma. The evolution was marked by an immediate pain relief and normalization of the mobility of the left lower limb.DiscussionThe SPECT/CT can increase the sensitivity and specificity of planar bone scintigraphy. It confirms the location of osteoid osteoma and defines its anatomical relationships in order to optimize surgical management.ConclusionThe SPECT/CT contributes significantly to the diagnosis of osteoid osteoma when radiological images are atypical or unusual clinical expression.     

La part de l’analyse phénoménologique dans l’étude de cas singulier

We argue that clinical psychiatry oscillates between two epistemological poles: inference and perception. The inferential approach categorises illnesses bottom up, from visible symptoms to the pathological category supposedly causing them. In doing so, psychiatry moves away from the possible instantaneous perception of a patient, as well as from illness as a changing, evolving, phenomenon. From a phenomenological point of view, the perceptive approach enables the therapist, within an encounter, to experience the emergence of an impression of a patient’s overall bearing, or attitude. Thanks to épochè, a sense of form, Gestalt will emerge. The clinical case, nevertheless, is always a construction, an intersubjective narrative about illness, recounted by the patient. Creating a library of clinical cases leads to the development of case types, each becoming a reference to which future clinical cases can be compared and categorised as belonging to a clinical family; it is the participant with respect to Plato’s eidos. Phenomenology contributes to clinical experience in that it makes possible the link between perception and inference, between subjective experience and intersubjective narrative, and between person and case type.     

évaluation des pratiques professionnelles dans le cadre de l’accréditation des établissements psychiatriques

As regards evaluation of professionnal practices (EPP), Formep’s has decided to stay in the limits of psychiatric institutions, for reason of experience. Every medical doctor working in these institutions is concerned by evaluation, but also institutions in the specific framework of V2 44, 45 and 46 references. The EPP is multidisciplinary and involves everybody who takes part of patient caring. Formep’s is adviser, training agent, and partner. Follow-up takes place both on-site and off-site all along the EPP, by a team including psychiatrists, medical practitioners, quality and risk management engineers. They are all experienced to work in psychiatric institutions. Formep’s program includes preliminary and definitive choice of themes, putting methology is place, work of teams, initial analysis of results and deviations, further work of teams, final analysis, which purpose is to improve practices and therefore medical benefit.     

Intérêt de l’imagerie hybride TEMP-TDM dans l’histiocytose langerhansienne osseuse. À propos d’un cas

Langerhans’ cell histiocytosis is a non-malignant proliferative disease of unknown etiology. It is a rare illness affecting mainly children and young adults with a male predominance. It can affect one or many organs. The bone locations are the most frequent. We present one case of multifocal Langerhans’ cell histiocytosis in a 22-year-old male patient followed for diabetes insipidus with an enlargement of the pituitary stalk at the magnetic resonance imaging (MRI), and a lytic bone lesion revealed in lumbar spine (L2) by ^99mTc-HMDP scintigraphy conducted in planar mode, and then in Single Photon Emission Computed Tomography coupled to Computed Tomography (SPECT/CT) in hybrid mode. To this end, we propose to highlight diagnostic gain of SPECT/CT compared with SPECT and planar scintigraphy to characterize radiotracer uptake abnormalities in bone in Langerhans’ cell histiocytosis.     

Place de l’embolisation percutanée de la varicocèle dans le traitement de l’infertilité

Objectives

To describe percutaneous embolization of varicocele and to evaluate the effect on fertility disorders.

Materials and methods

One hundred nineteen patients, aged 11 to 48 years, underwent percutaneous embolization for varicocele indicated by a fertility disorder in 23% of cases. Correction of the varicocele and resolution of associated pain, improvement of testicular trophicity and the effect on fertility were studied and a review of the literature was performed.

Results

Percutaneous embolization was performed using neuroleptanalgesia on an outpatient basis. The technique combined venous sclerotherapy and placement of coils in the gonadal vein. The technique was successful in 95% of cases and one complication was observed. At 3 months, the varicocele and related pain had resolved in 98% of treated patients. According to previous reports in the literature, the relations between varicocele and fertility disorders are still unclear, but improvement of fertility (semen quality and conception rates) after varicocele repair has been established.

Conclusion

Although the consequences of varicocele on fertility have not been fully elucidated, treatment of varicocele appears to be beneficial. Percutaneous embolization of varicocele is a safe and effective alternative to surgery. This technique, based on a urological and radiological consensus, is the first-line treatment for varicocele in our institution.     

Intérêt de l’imagerie hybride TEMP/TDM pour la scintigraphie des récepteurs de la somatostatine dans le bilan des tumeurs endocrines gastro-entéro-pancréatiques

In this work, we have evaluated the potential of image fusion and attenuation correction (AC) of SPECT-CT imaging for the assessment of gastro-entero-pancreatic endocrine tumors by somatostatin receptor scintigraphy (SRS).MethodAfter optimisation of acquisition and reconstruction parameters, we have evaluated, in a prospective study, SRS performed over a period of one year. We have compared visual interpretations of planar and tomographic images versus SPECT/CT images to determine if anatomical localisation and diagnostic contributions are improved. In a semi-quantitative analysis of pathological foci, we have measured maximal intensity values (T_max), tumour to background ratios (T/B) and tumour contrasts (Ct) with and without AC.ResultsIn 25 SRS, visual analysis has shown anatomical localisation improvements in 60% of cases (CI95%, 39–79) and diagnostic improvements in 64% of cases (CI95%, 43–82). Doubtful foci proportion changed from 44 to 11%. In the semi-quantitative analysis of 41 pathological foci, Wilcoxon matched-pairs tests showed significantly higher T_max, T/B and Ct values after AC.ConclusionSPECT/CT imaging improves diagnostic quality of SRS thanks to a better foci localisation and a better lesional contrast in the image.     

Physiopathologie des troubles de l’érection chez l’homme paraplégique

Peripheral mechanisms responsible for penile erection are dependant upon a complex control by the nervous system, including peripheral nervous pathways, spinally mediated reflex loops and supraspinal nervous structures. Spinal cord injury is accompanied by a partial or a complete modification of these controls. In relation to the reflexogenic or psychogenic origin of penile erection, spinal cord injury does not cause the same effects. Reflexogenic erections sitll occur after spinal cord injury at a suprasacral level. After lesions at a level lower than the thoracolumbar spinal cord, tumescence following psychogenic stimulation has been observed. The hypotheses resulting from clinical and experimental observations and explaining the differences at the origin of these response are detailed. The recent developments in the neurophysiology of penile erection and the role of neurotransmitters allow a more analytical approach of the phenomenous and also bring new insights into possible compensatory pathways following spinal cord injury.     

Applications cliniques de l’imagerie hybride TEP-IRM

This paper reports the results of a preliminary study evaluating the feasibility and performance of a first whole body hybrid PET/MR scanner allowing sequential acquisition of co-registered MR and PET images. Sixty-two patients underwent whole body PET/MR imaging immediately after a clinical PET/CT. The hybrid device consists of a 3T MR and a time-of-flight PET scanner sharing a single bed allowing sequential acquisition of co-registered MR and PET images. Imaging protocols included a whole body MR used for attenuation correction of PET followed by high-resolution diagnostic MR. Image analysis included visual identification of radiotracer uptake in tumors and measurement of standardized uptake values (SUV) in tumoral lesions and in normal organs. PET images acquired in the PET/MR with a delay of 85 ± 22 minutes (range 49–120 minutes) showed perfect correlation and identical diagnostic quality compared to PET/CT. In 42 patients (68%), additional high-resolution MR sequences were acquired for clinical diagnosis showing excellent quality without any visually detectable artifacts. SUV measurements of tumor lesions obtained after correction with MR attenuation maps showed an excellent correlation with PET/CT (R² = 0.89 and R² = 0.95 for mean and maximum tissue uptake respectively). Due to the delay between the two studies, changes in tracer uptake biodistribution of normal tissue were observed. Our preliminary data show that whole body PET/MR is clinically applicable in oncologic patients yielding a comparable diagnostic performance as PET/CT with respect to lesion detection and localization.