Évaluation de la TEP au 18F-FDG dans la tuberculose extrapulmonaire : premiers résultats d’une étude pilote observationnelle

Aim

Extrapulmonary tuberculosis treatment is difficult to assess and there is a need for new tools. The aim of this observational pilot study is to evaluate the potential role of 18F-FDG PET/CT in the initial staging and treatment evaluation of extrapulmonary tuberculosis.

Methods

Twenty-eight patients were included between January 2009 and 2010. Twenty-three had a 18F-FDG PET/CT before treatment and/or during and/or after treatment. All patients will be followed for 18 months after the end of treatment. A control group of five patients with previous history of tuberculosis was also included and PET/CT was performed.

Results

Three cases of differential diagnosis were excluded of the study. The initial PET for staging showed additional lesions in 8/10 patients compared to conventional imaging. At the end of treatment, 6/11 patients had a negative PET, and 5/11 patients had a positive PET. PET had a significant clinical impact for 3/10 patients at initial staging (guiding biopsy or increase of planned treatment duration), and for 3/16 during follow up (extend or early interruption of the treatment). All PET scans in the control group were negative.

Conclusion

18F-FDG PET has an excellent sensitivity for the detection of extrapulmonary tuberculosis lesion and excellent negative predictive values. The impact of initial PET staging seems significant. The interest of 18F-FDG PET for the evaluation of response to treatment remains to be assessed and will be correlated with patients’ follow up in a second phase of this study.     

Interet de la microinjection de spermatozoides sous la zone pellucide pour le traitement de certaines sterilites masculines

Sub-zonal insemination (SUZI) was evaluated, in a randomized prospective study, as a treatment for certain specific types of male factor infertility. Patients were classified according to the results of an extensive semen analysis as being either IVF failure with either normal or subnormal semen quality, specific (e.g. absent outer dynein arms) or non-specific flagellar dyskinesia, or oligoasthenoteratozoospermia. SUZI was found to be an efficient technique for achieving fertilization and pregnancy for all these indications, while there was a total failure of fertilization in the control, in-vitro inseminated oocytes. A total of 395 oocytes were microinjected and 133 fertilized, among which 75 (19% overall) were diploid. More than 81% of these zygotes cleaved normally, and 31 embryo transfers resulted in seven pregnancies. However, results varied widely between the various indications, suggesting that the underlying pathology responsible for the sterility may influence gamete interaction and early embryonic development independantly of the SUZI technique.     

Indications de la TEP-FDG en oncologie. Mise à jour selon les recommandations de prise en charge européennes et américaines

[18F]-Fluoro-2-Deoxy-D-Glucose-Positon Emission Tomography (PET) is a powerful tool which availability increases in France. The oncological PET indications are plentiful and are increasing. Yet, its cost is significant. Thus, it is important to use PET in validated indications and/or in situations in which it can improve the patient management. The first part of this work reviews the PET indications in oncology, according to the international clinical practice guidelines (European Society for Medical Oncology [ESMO] and National Comprehensive Cancer Network [NCCN]), and compares those with the French guidelines (Guide de bon usage [GBU] des examens d’imagerie médicale). The second part assesses the indication distribution of 400 consecutive PET-CT studies in an against cancer center, according to the cancer type and confronts those with the guidelines.     

A novel IL-18BP ELISA shows elevated serum IL-18BP in sepsis and extensive decrease of free IL-18

IL-18 binding protein (IL-18BP) is a circulating antagonist of the proinflammatory Th1 cytokine IL-18. It effectively blocks IL-18 by forming a 1:1 high affinity (Kd=400 pM) complex, exhibiting a very low dissociation rate. We have developed a sandwich ELISA for IL-18BPa and determined its limit of detection (62 pg/ml). Interference by IL-18 and related cytokines, as well as cross reactivity with other IL-18BP isoforms (b, c, and d) were determined. Using this ELISA, we measured serum IL-18BPa in large cohorts of healthy individuals and in septic patients. Serum IL-18BPa in healthy individuals was 2.15+/-0.15 ng/ml (range 0.5-7 ng/ml). In sepsis, the level rose to 21.9+/-1.44 ng/ml (range 4-132 ng/ml). Total IL-18 was measured in the same sera by an electrochemiluminescence assay and free IL-18 was calculated based on the mass action law. Total IL-18 was low in healthy individuals (64+/-17 pg/ml) and most of it ( approximately 85%) was in its free form. Total IL-18 and IL-18BPa were both elevated in sepsis patients upon admission (1.5+/-0.4 ng/ml and 28.6+/-4.5 ng/ml, respectively). At these levels, most of the IL-18 is bound to IL-18BPa, however the remaining free IL-18 is still higher than in healthy individuals. We conclude that IL-18BPa considerably inhibits circulating IL-18 in sepsis. Yet, exogenous administration of IL-18BPa may further reduce circulating IL-18 activity.     

Évaluation des pratiques professionnelles. Pertinence des indications de la tomographie à émission de positons en cancérologie

IntroductionAs part of the health care quality and safety policy in France, Professional Practice Assessment (PPA) are mandatory in the health services “certification” process. We present our study regarding the pertinence of Positron Emission Tomography (PET) indications in oncology.Materials and methodsA multidisciplinary task group used the Quick Audit method with two rounds of 100 request forms each. The assessment list of criteria comprised four items of decreasing relevance grading the PET scans clinical indications, which were derived from the three French published guidelines (SOR [FNCLCC], “Guide du bon usage des examens d’imagerie médicale” [SFR-SFMN], “Guide pour la rédaction de protocoles pour la TEP au FDG en cancérologie” [SFMN]) and five additional items: clinical information, patient's body weight, previous treatments dates, diabetes, claustrophobia.ResultsThe first round showed that 68% of the requested scans corresponded to the two most relevant groups of indications (SOR Standards and Options). The request forms were correctly filled in regarding the clinical information, but this was not the case for the other items we tested. Several actions were conducted: dedicated PET request form, availability of the SOR on the hospital intranet, boost of the referring physicians awareness during the multidisciplinary oncology meetings (Réunions de Concertation Pluridisciplinaires RCP). The second round showed a better pertinence of the PET scans indications (75% versus 68%); the patient's body weight was more frequently mentioned on the request form.DiscussionThis study is an example of PPA in our discipline. It led to an improvement of the oncologic PET scans clinical indications in our hospital. This work is pursued in everyday discussion with the referring clinicians, especially during the RCP.     

La tomographie par émission de positons en cardiologie

Cardiovascular PET imaging is progressively emerging, owing to wider availability of cameras for non-oncology indications, as well as to the development of dedicated imaging agents. This article briefly reviews main indications of cardiovascular PET.     

Apports de l’acquisition TDM couplée à la scintigraphie pulmonaire dans l’exploration d’une suspicion d’embolie pulmonaire

Pulmonary embolism is a frequent disease difficult to diagnose because of heterogeneous clinical presentation. Pulmonary embolism diagnosis requires additional examinations, which are guided by clinical probability scores. The ventilation/perfusion scintigraphy is a validated technic in pulmonary embolism diagnosis strategies, which represents one of its most important indications. In the past years, the technique of scintigraphy evolved with the appearance of hybrid cameras, allowing the realization of tomoscintigraphy coupled with computerised tomodensitometry (CT). One of the major interests of this technique is the possibility of considering alternative diagnosis in case of negative result of scintigraphy. The purpose of this article is to offer nuclear medicine physicians a review of the alternative diagnoses that can be found during pulmonary ventilation/perfusion tomoscintigraphy according to the underlying scintigraphic and morphological abnormalities. In this review, we will first on diseases responsible for: a mismatch (pathological perfusion and normal ventilation), an inverted mismatch (normal perfusion and pathological ventilation) and for associated disorders in ventilation and in perfusion patterns (identically abnormal perfusion and ventilation). The final part will address some specific CT features that can be encountered on a low dose CT centered on thorax.     

Précautions,pièges et artefacts en TEP/TDM au 18FDG : généralités et cas particulier des pathologies de la tête et du cou

The PET/CT imaging with 18F-FDG is an essential diagnostic tool in the management of many diseases today. However, because of its functional and metabolic nature, it requires for its realization the respect of certain precautions to avoid abnormal images or false negative tests. Moreover, in the context of head and neck diseases, knowledge of anatomy and physiological uptakes appears essential for quality interpretation. In this paper, we illustrate with several personal circumstances or particular clinical situations from literature, the potential pitfalls and artifacts that could lead to misinterpretation.     

Le Moustérien du Zagros : une vision synthétique à partir de la grotte de Shanidar

The Zagros Mousterian is a Middle Palaeolithic techno-typological lithic complex, found down the length of the Zagros mountain range in Iraq and Iran. It is associated with Neanderthal skeletal remains at four sites, most famously Shanidar Cave. Dating is problematic, but the indications are that Neanderthals with this cultural apparatus were present in the Zagros region from the beginning of the last interglacial (Marine Isotope Stage 5e) c.130.000 years ago through to c. 40.000 years ago during the last glacial. The humid deciduous woodland of MIS 5 was replaced by increasingly dry steppe in MIS 4 and MIS 3. Microfaunal assemblages and paleosols indicate that Neanderthals visited Shanidar Cave when environmental conditions were broadly similar to those of today, primarily in the humid phases of MIS 5 and then during brief climatic ameliorations in MIS 4 and MIS 3 that may correlate with Dansgaard-Oescheger events. Caves with Mousterian occupations at high altitudes suggest that they, too, were used by Neanderthals when conditions were not dissimilar to those of today. The indications are that the Zagros Mousterian represents the seasonal activities of highly mobile small and dispersed groups of Neanderthal foragers connected in social networks of shared cultural values and/or norms.     

Prise en charge des cancers de la prostate : points de vue du radiothérapeute

In 2011, the prostate cancer positions itself clearly like a problem of public health. The radiotherapy has shown these twenty last years significant improvements with the advent of the three-dimensional conformation radiotherapy as a standard in the treatment of the adenocarcinoma prostate cancer, and now with the contribution of the modulation of intensity which makes it possible to consider an increment of amount on estimated target volume without toxicity added to the organs at risks. Radio-hormonotherapy association for high-risk cancers also went to current practice. The nuclear medicine through new tracers and new indications probably will allow the experts dealing with these patients to better define the indications and to better distinguish the patients who will profit authentically from a therapeutic strategy more than of another, and even to associate them…     

Prescription et pratique de la recherche des microdélétions du chromosome Y en France: résultats de l’enquête nationale réalisée sous l’égide de la Société d’Andrologie de Langue Française

Screening for Y chromosome microdeletions is recommended in cases of severe impaired spermatogenesis. Improvement of molecular biology techniques has made this diagnosis more accessible in routine practice when evaluation of male infertility is necessary. However, the diagnosis of Y chromosome microdeletions is not proposed by all IVF centres. The aim of the present study was to specify the prescribing conditions (indication, financing) and practical conduct (methods, billing) for this analysis in France. We observed that microdeletion screening is a rapidly expanding activity. The development of a consensus on the indications for this screening and a standardised technique, with a national quality control, appears to be necessary. The funding of this analysis by French Social Security appears to be an essential step to ensure widespread use in routine practice. Lastly, the answers to our questionnaire revealed a strong demand for information concerning this analysis.     

Tomographie par émission de positons et cancer de la prostate

Positron emission tomography (PET) is a major imaging modality in oncology. Fluorodeoxyglucose (FDG) PET is of limited usefulness in prostate cancer, be it for initial staging or for detection of recurrence. New PET tracers could improve PET performances in prostate cancer staging and when recurrence is suspected. Lipid metabolism tracers, such as choline and fluorine-18-labelled choline analogues, seem to be promising in these indications. The impact of these PET examinations on patient management should be further evaluated, taking into consideration the new therapeutic strategies, in particular salvage local treatment in case of isolated local recurrence.     

La pratique de l’IRM mammaire au centre hospitalier de Chambéry

ObjectiveTo determine indications, technique and results of breast MRI performed at Chambery hospital (CH).Patients and methodsAnalytical retrospective study of 12 months, conducted at CH. It involved the analyzing of 100 breast MRI examinations performed in 84 patients using a brand device Siemens Magneton Area^®.ResultsThe mean age of patients was 56.2 years. The indications for breast MRI were the assessment of local and regional extension of breast cancer (28%), the results of monitoring of neoadjuvant chemotherapy (22%), the research of local recurrence after conservative treatment (14%) and cases of diagnostic discrepancies (13%). The most commonly used sequences were axial T1 ES (91%), axial T2 STIR (91%) and axial T1 with gadolinium injection (97%). The assessment of locoregional extension revealed multifocal invasion in 14 cases, pectoral in 3 cases, lymph node in 7 cases and skin in 4 cases. Concerning the monitoring of neoadjuvant chemotherapy, tumor involution was found in 10 patients and stability in 3 others. The distinction between tumor recurrence and postoperative scar showed 10 negative cases and 4 cases of tumor recurrence.ConclusionBreast MRI is an excellent non-invasive method for studying fully and satisfactorily within. It is mainly practiced in the CH to the extension of cancer and monitoring neoadjuvant chemotherapy balance.     

Evaluation de l’apport de la méthode d’observation des spermatozoïdes à fort grossissement en ICSI

Due to the growing interest in the method of high-magnification sperm observation and selection proposed for the specific indication of ICSI failure, the authors evaluated the technique in unselected ICSI. The aim of this study was to evaluate the relevance of Motile Sperm Organelle Morphology Examination (MSOME) compared with usual selection performed in ICSI. In a series of conventionally selected sperm for ICSI, the number with an abnormal appearance on high magnification was determined and the predictive value of this parameter on ICSI outcome was assessed. The study included 25 successive unselected ICSI attempts in the IVF Laboratory of Poissy Hospital (France). ICSI were performed according to usual protocols used in the laboratory. Twenty five motile spermatozoa of the migrated fraction, still available after ICSI, and “injectable— according to conventional morphology assessment in ICSI (“normal” or “as normal as possible” with magnification of ×200–400) were assessed by MSOME (higher than ×4500) and classified according to criteria adapted from Bartoov’s work and taking into account David’s sperm morphology classification. We compared the results of MSOME and ICSI results. In this small series of ICSI with diverse indications, we found very high frequencies of abnormalities (more than 70%), particularly nuclear vacuoles. No predictive value of the morphology of sperm assessed with high magnification (including vacuoles) was found for fertilization rate, embryo quality and ICSI outcome. In contrast with previous reports, pregnancies were obtained with very abnormal sperms. In this series of unselected ICSI, nuclear vacuoles do not seem to have a pejorative impact on pregnancy outcome. This study raises several perspectives. It would be interesting to understand the “anatomical” basis for vacuoles observed with MSOME and their meaning. The question of the phenotype-genotype relation, i.e. the possible correlation between sperm morphology and genetic content could be investigated. Finally, a prospective analysis should be performed in clearly defined indications to validate the potential applications of the method for high-magnification sperm observation and selection.     

État actuel de l’utilisation en essais cliniques de molécules radiomarquées au 68Ga en France. Exemple du site de Bordeaux

Production of ⁶⁸Ga-radiopharmaceuticals for Positron Emission Tomography coupled with Computed Tomography (PET/CT) is increasing. These developments are today consolidated by the availability in France of a somatostatin receptor agonist (DOTATOC, Somakit^®), under marketed authorization, and two Prostate Specific Membrane Antigen (PSMA) inhibitors (PSMA-11 and PSMA-617) under nominative temporary authorization of use. The unquestionable success of these radiopharmaceuticals and their uses within diagnostic strategies represent clinical trials carried out using ⁶⁸Ga-DOTATOC and ⁶⁸Ga-PSMA-11 mainly. Today, new indications and new ⁶⁸Ga-radiopharmaceuticals arise to further promote PET/CT molecular imaging. In this article, we would share our experience to establish such clinical trials.     

Place actuelle de la biologie dans l’exploration et le suivi de l’allergie

The allergy disease requires an early diagnosis which, in addition to the management of the disease at its initial stage, will prevent its development towards potentially more severe symptoms. In primary care, screening tests allow to investigate the underlying cause of the symptoms and to confirm or exclude an allergic condition. They were recently completed by a test specially dedicated to the infant, which takes into account the predominance of the food allergens at this age. Specific IgE tests contribute, by the identification of the offending allergens, to implement a specific treatment (more particularly allergen avoidance) and to follow the development of the disease over time. The last scientific and technological advances allow from now on to refine the exploration at the molecular level and the recent development of tests with allergenic components offers new perspectives to the in vitro diagnostic as well as new indications.