Techniques d’imagerie de la cardiopathie ischémique : le point de vue du clinicien

Coronary angiography often remains an unavoidable gold standard in cardiology practice for determining the severity, extent and prognosis of coronary artery disease and for therapeutic decision making, although established non-invasive testing – such as myocardial perfusion imaging or stress echocardiography – have demonstrated their diagnostic value and their incremental pronostic value over coronary angiography. Newer noninvasive techniques, such as multidetector computed tomography and magnetic resonance imaging, are currently being validated and will very soon be considered as alternatives to these imaging modalities in clinical practice. Facing this wide choice of tests, the cardiology community has the difficult task to determine the role and place of these various investigating techniques and to evaluate their resource implications, in other words, to optimize the cost-efficacy and ratios in the management of coronary artery disease.     

Apport de la médecine nucléaire dans le cancer du sein : à propos de 3 cas cliniques

Presentation of three clinical cases that illustrate the current multidisciplinary management in breast cancer, and the role of nuclear medicine in diagnostic strategies.     

Apport de la TEP/TDM au FDG en cancérologie de l’intestin grêle

This article focuses on the indication for FDG PET/CT in case of tumours of the small intestine, neuro-endocrine tumours excluded. The adenocarcinomas, lymphomas and sarcomas (including stromal tumours or GIST) are studied. There is no specific recommendation for FDG PET/CT in adenocarcinomas, extremely rare in comparison with colorectal adenocarcinomas. However, the utility of FDG PET/CT has been reported in clinical cases for detection and staging, especially in patients with high risk of developing the disease (Crohn's disease being the most important risk factor). The primary lymphomas of the small gut are also very rare, corresponding in all cases to non-Hodgkin lymphomas, for which the role of FDG PET/CT is recognised in follicular lymphoma, large B-cell lymphoma and Burkitt lymphoma. The stromal tumours correspond to the most frequent sarcomas. Stromal tumours in the small intestine are less frequent in the small intestine than in the stomach. The role of FDG PET/CT is well established in stromal tumours for the staging of the disease and for determining the efficacy of therapy with tyrosine kinase inhibitor. FDG PET is especially effective to evaluate the response since the radiologic criteria are difficult to assess, based not on the decrease of size of the lesions but on the decrease of density and of contrast enhance.     

Évaluation de l’irradiation additionnelle des patients de médecine nucléaire en imagerie hybride TEMP/TDM

One hundred and ten consecutive patients and 130 SPECT/CT examinations were involved in this retrospective study that focused on the evaluation of the excess of dose contributed by the CT to the patient during the SPECT/CT explorations, for routine examinations in nuclear medicine. The average age of patients was 53 years. In this study, it appeared that irradiation induced by a low dose CT combined with a SPECT is low compared to that of a diagnostic CT. The main risk on patients is the occurrence of radiation-induced cancer. In our study, this increased risk induced by the additional CT with low dose settings in line with SPECT examination, is not significant and does not exceed 0.026%. By weighing the diagnostic value of SPECT/CT examination with that of a stand-alone SPECT examination dosimetric “incremental cost” is justified because of its direct clinical benefit conveyed to the patient.     

Tendances en médecine nucléaire : renouvellement du TEP/TDM au sein du service de médecine nucléaire du centre hospitalier universitaire Vaudois (CHUV), Suisse

After a technology life of a machine imaging positron emission tomography combined with computed tomography (PET/CT), the nuclear medicine department of the Centre hospitalier universitaire Vaudois (CHUV) has renewed its unique equipment. He realized at that time, a number of reorganizations for the arrival of the new “PET/CT”. This project is crucial for the nuclear medicine department and should be part of a rigorous approach to both the organization of replacement of equipment and on the adaptation of the host structure. The CHUV has chosen a new generation machine reducing the examination time, the amount of radiotracer and thus the dose to the patient while increasing the performance of lesion detection. To take full advantage of this technology, it was necessary to establish the needs of all stakeholders nuclear medicine department and associated them in the procedure in order to acquire. This process was organized by the Biomedical Engineering Department in order to offer the new technology to meet cost to expectations of doctors and patients.     

Retentissement sexuel, conjugal et social d’une population d’hommes stériles consultants en Andrologie: le point de vue du psychiatre de liaison

Material and methods

The study population consisted of 39 subjects divided into two groups: 21 azoospermic males and 18 oligoazoospermic males. These men were selected in andrology departments over a period of six months. The andrology and liaison psychiatry departments of Lille university hospital established a general infertility questionnaire. This semi-structured questionnaire comprising 40 questions was based on clinical experience and describes the clinical and symptomatic context of infertility. An individual 50-item questionnaire was then used to analyse the psychosocial, marital and sexual effects of male infertility and the representation of the psychiatrist in the andrology department.

Results

One third of patients discovered the diagnosis of infertility when the biologist gave them the results of the semen analysis. Our patients initially envisaged marital, psychological and social problems, but very few sexual problems. They imagined that infertility was more disturbing for women than for men, from a psychological and sexual point of view. 82% of our subjects imagined that their partner had no sexual problems. 48.7% of them thought that their partner had no psychological difficulties related to their infertility. The oligoasthenospermia group considered that the partner had significantly more “psychological difficulties” compared to the azoospermia group. 41% of our patients felt guilty towards their partner because of their infertility diagnosis. 10.3% of patients presented sexual disorders before the diagnosis of male infertility and 25.6% presented sexual disorders after this diagnosis. Contrary to data in the literature, a major change of sexuality was not observed in the majority of the couples after the diagnosis. When sexuality changed, it generally consisted of a reduction of the frequency of sexual relations. Among the patients who reported sexual difficulties, only 40% related them to infertility. 50% did not report any relationship between the psychological difficulties related to infertility and the sexual difficulties. Contrary to the data in the literature, neither the loss of spontaneity during sexual relations, nor the complementary investigations necessary for artificial insemination had any influence on sexuality. 89.8% of our patients are ready to change their sexual practices in order to be more fertile without causing any sexual or psychological problems. However, only 34.3% of patients reported a concern about reproductive efficacy during sexual relations. A more marked sexuality/reproduction dissociation was observed in oligoazoospermic males than in azoospermic males. 28.2% of patients reported that talking about their sexual and/or psychological problems with a psychiatrist was helpful.

Conclusion

Many contradictions and underestimations were observed in the answers to the questions. We confirmed the existence of a psychological and sexual distress, but which was quantitatively less severe than that described in “gynaecological” populations. However, a real psychological and sexual distress does exist in our population, which is why we propose from the outset a psychosomatic and sexological treatment of infertility in order to prevent the onset of these sexual difficulties. Our questionnaire was based on clinical experience and helped our patients to identify their psychological and sexual difficulties related to infertility and its treatment. It would therefore be useful for the practitioner, andrologist or psychiatrist, to help the patient express the effects related to this “new medicalized sexuality”.     

Impact diagnostique de l’imagerie hybride TEMP/TDM dans la prise en charge des neuroblastomes. Expérience du service de médecine nucléaire du CHU Mohammed VI de Marrakech

IntroductionThe neuroblastoma is a malignant pediatric tumor of the peripheral sympathetic nervous system. This is the pediatric solid extracranial tumor most common and accounts for approximately 8 to 10% of childhood cancers. The diagnosis is based on imaging showing a tumor developed at the expense of the sympathetic nervous system, increased urinary catecholamines, increased uptake of meta-iodo-benzylguanidine (MIBG) and histology who finds a malignant proliferation of small round cells. An assessment of the tumor mass and its extension are required to assess the prognosis and adapt the treatment. The MIBG scintigraphy is a non-invasive imaging technique that can evaluate with a single review the totality of the tumor extension. The single-photon emission computed tomography/computed tomography (SPECT/CT) improves the sensitivity of the examination, it allows an anatomical and functional study and improves the anatomical localization of scintigraphic uptake observed. The purpose of our work is to illustrate the contribution of the SPECT/CT in addition to the planar MIBG scintigraphy in the diagnosis and staging of neuroblastoma about four cases.Case reportClinical case 1: a 4-year old child, presented for 2 months abdominal pain. In the clinical examination, he presented a hard abdominal mass, painless and right paramedian. Abdominal ultrasound showed a right retroperitoneal mass with lymph nodes. The dosage of urinary catecholamines was increased. The ¹³¹I-MIBG scintigraphy showed an image for a right adrenal neuroblastoma measuring 8.6 × 4.5 cm. Surgical excision of the adrenal mass revealed in the anatomopathologic study a malignant tumoral proliferation with round cells compatible with a neuroblastoma. Clinical case 2: a 10-month old infant, presented since 15 days an exophtalmia with poor general status. The clinical examination showed a right abdominal mass and a bilateral periorbital ecchymosis. The radiography of the thorax showed a widening mediastinal. Abdominal echography showed a tissular mass of the right adrenal gland with retroperitoneal lymph nodes and an ascites. The dosage of urinary catecholamines was increased. The ¹³¹I-MIBG scintigraphy showed a right adrenal neuroblastoma measuring 6.4 × 2.7 cm with orbital bone metastases in favor of a Hutchinson syndrome. Clinical case 3: a 2-month old infant, followed since 1 month for bilateral adrenal neuroblastoma. The clinical examination showed an important abdominal distension with bluish nodules under skin. The abdominal echography and the abdomino-pelvic TDM showed two adrenal masses corresponding to a bilateral neuroblastoma with liver metastases. The ¹³¹I-MIBG scintigraphy showed two adrenal masses measuring respectively 6.5 × 3.4 cm and 8 × 6 cm, with liver and skin metastases in favor of 4S neuroblastoma with bilateral adrenal tumors. Clinical case 4: a 3-year old child, followed for left adrenal neuroblastoma with multiple bone metastases. The clinical examination showed a left abdominal mass with exophtalmia and right palpebral ecchymosis. The radiography of the thorax showed a widening of the mediastin with repression of the paravertebral right line. Abdominal echography showed a left retroperitoneal tissular mass measuring 9.2 × 5.2 cm. The abdomino-pelvic TDM showed a left adrenal tumor with lumbar vertebral bone metastases. A first ¹³¹I-MIBG scan showed a left neuroblastoma with multiple bone metastases in the right orbit, the right humerus, the occipital bone, the right scapula and spine (D10, D11, L1, L3, S1). The child was treated by 5 courses of chemotherapy (protocol HRNLB/10). The ¹³¹I-MIBG scan control showed a regression of neuroblastoma size (1.4 × 1.2 cm) with loss of bone metastases of the occipital bone, the right scapula and spine.DiscussionThe MIBG scintigraphy is a simple, non-invasive examination that has excellent sensitivity and specificity in detection of neuroblastoma and especially in invasion bone marrow and in evaluation of the therapeutic response. The hybrid SPECT/CT imaging improve the performance of the scintigraphy as well in sensibility, toward the deep localization, as in specificity for images poorly defined in planar imaging.     

Apport de la TEP/TDM dans les cancers broncho-pulmonaires : étude d’une série de 35 cas

Lung cancer is one of the most common cancers in Morocco. Currently, PET/CT with FDG is described as the best suited imaging test to evaluate the initial extension of this type of cancer in it non-metastatic variety. Our study confirms the literature data, showing the superiority of PET/CT versus CT in the initial staging of lung non-small cell carcinoma.     

Communication interventriculaire avec défaillance cardiaque chez le nouveau-né et le nourrisson: Evaluation du traitement médical

Twenty-seven infants with ventricular septal defects and in cardiac failure were followed regularly under medical treatment for an average period of 17 months. The diagnosis was proved in all cases by cardiac catheterization.At the end of the follow-up period, the patients could be classified as follows: Sixteen patients showed no change in their cardiovascular status, and six had signs of pulmonary infundibular stenosis. One child had died from bronchopneumonia. Another was classified as having probable functional closure of the defect. Finally, three other children, because of failure of medical treatment, underwent banding of the pulmonary artery. One died during the operation.It is concluded that the great majority of patients with ventricular septal defects and cardiac failure can be carried successfully under medical management until the age at which corrective surgery is feasible. Palliative procedures which in themselves carry a fairly high mortality risk should be used only as a last resort.     

Apport de la tomoscintigraphie au technétium 99 m dans le diagnostic des duplications gastriques de l’enfant : à propos d’un cas

Gastric duplications (GD) are rare congenital digestive malformations of the child. Their diagnosis often involves multiple medical imaging modalities ranging from ultrasound to CT or MRI. Scintigraphy is an excellent diagnostic method rarely used especially when the discovery mode of GD is not associated with gastro-intestinal bleeding. We report a case of a non-communicating and non-hemorrhagic GD discovered in a 6-year-old girl whose exploration has benefited many ways including SPECT imaging after intravenous injection of Tc-99 m pertechnetate. Our goal is to focus on the role of scintigraphy in the diagnostic management of the DG of the child and to discuss the opportunity of the other imaging techniques in the exploration of this pathology.     

Intérêt de l’imagerie hybride TEMP/TDM pour la détection de l’ectopie parathyroïdienne. Expérience du service de médecine nucléaire – CHU Mohammed VI,Marrakech

IntroductionHyperparathyroidism due to a parathyroid ectopia is a rare disease; it is the most common cause of persistent or recurrent hyperparathyroidism. Its treatment is exclusively surgical and the results of the surgery benefit from the contribution of preoperative imaging techniques. The aim of this work is to illustrate the interest of the single photon emission computed tomography/computed tomography (SPECT/CT) in the detection and treatment of ectopic parathyroid orientation.Case reportClinical case 1: a 41-year-old patient was followed for persistent primary hyperparathyroidism revealed by brown tumors at the level of the lower extremity of the right femur and tibia. The rate of parathormone was 1987.4 pg/mL. The cervical echography and the scanning were not decisive. The SPECT/CT, performed during a ^99mTc-MIBI scintigraphy and the same for the 2nd clinical case, has showed an area of high uptake projecting behind the left sternoclavicular joint. The diagnosis of ectopic parathyroid localization was retained. Resection and pathologic examination of the surgical specimen revealed parathyroid adenoma tissue. The evolution was marked by a normalization of the rate of parathormone. Clinical case 2: a 71-year-old patient who presents a clinico-biological board of primitive persistent hyperparathyroidism. A first scintigraphy (^99mTc-MIBI) realized in 2010 was negative. The rate of parathormone was 969 ng/L, the rate of calcium was 2.90 mmol/L. Two cervical ultrasound were normal. The SPECT/CT has objectified an area of high uptake in projection at the upper floor of the middle mediastinum. The diagnosis of ectopic parathyroid localization was retained. Surgical resection and histological study revealed a parathyroid adenoma tissue. The evolution was marked by a normalization of the rate of parathormone.DiscussionThe SPECT/CT has an important role in the management of patients with persistent or recurrent hyperparathyroidism. It can usually visualize ectopic parathyroid injury, specify its size and anatomic relationships to optimize surgical management.     

Distribution physiologique cérébrale et corps entier du 18F-DPA-714 en TEP/TDM

ObjectiveTo investigate the physiological biodistribution of N,N-diethyl-2-(2 – (4 – (2-fluoroethoxy) phenyl) -5,7-dimethylpyrazolo [1,5] pyrimidin-3-yl) acetamide labeled with fluorine 18 (¹⁸F-DPA-714) in humans, by PET/CT in the brain and the whole body. The DPA-714 is a ligand of the translocator protein (Translocator Protein kDa or TSPO), protein overexpressed by microglia in case of neuroinflammation.Materials and methodsDynamic PET/CT brain acquisitions were performed in six healthy volunteers for 90 minutes after intravenous injection of ¹⁸F-DPA-714. Brain biodistribution of ¹⁸F-DPA-714 was assessed visually and using regions of interest (ROI), according to MNI AAL guidelines in order to obtain the activity/time curves for each brain region predefined. One of the subjects was also included whole body PET/CT acquisitions 1 hour after injection of ¹⁸F-DPA-714, allowing visual analysis and semi-quantitative distribution of the tracer, by definition of ROI and SUVs max computation.ResultsThe maximum brain uptake of ¹⁸F-DPA-714 was visualized at 3.5 minutes after injection, gray matter, mostly thalamic. This peak was followed by two elimination phases: an initial rapid phase (3.5 to 35 minutes) and a slower phase until the end of recording. Uptake of ¹⁸F-DPA-714 was generally consistent across brain structures analyzed. The whole body images show significant activity in the gallbladder, spine and salivary glands under the jaw, in accordance with previous published studies using other radioligands for TSPO.ConclusionThis very preliminary study confirms that the brain biodistribution of ¹⁸F-DPA-714 makes it an interesting marker of neuroinflammation. This work allows to recommend a PET protocol acquisition. However, it now seems necessary to implement these findings in patients referred for brain conditions.