L’hyperaldostéronisme primaire (HAP) constitue une cause grandissante d’hypertension artérielle en apparence essentielle (jusqu’à 15 % des patients hypertendus).
L’HAP peut exister même en l’absence ...d’hypertention artérielle (HTA) ou d’hypokaliémie, précocement reconnu au stade
d’«
incidentalome »
radiologique ou biologique.
Des valeurs paradoxalement normales de l’aldostérone plasmatique en situation de rénine ou d’activité rénine plasmatique basses, d’hypokaliémie, suffisent à évoquer l’HAP, mieux affirmé par l’accroissement du rapport aldostérone/ARP.
La tomodensitométrie (TDM) en coupes fines constitue la seule exploration morphologique indispensable. Les examens spécialisés (scintigraphie à l’iodocholestérol sous freinage, prélèvements veineux dans l’effluent)
n’ont d’intérêt que pour les patients susceptibles de relever de la chirurgie.
En cas de sécrétion unilatérale ou largement asymétrique, l’intervention chirurgicale est à recommander particulièrement en cas d’HTA ou d’hypokaliémie médicalement non contrôlées, en cas d’intolérance au traitement, particulièrement dans le sexe masculin.
Primary hyperaldosteronism is a growing cause of apparently essential hypertension (until 15
% of patients with hypertension).
Primary hyperaldosteronism can now be recognized even for patients without hypertension or hypokaliemia.
Paradoxically normal levels of aldosterone when serum renin levels and/or plasmatic renin activity and/or kaliemia are low, lead to suggest primary hyperaldostéronism. High values of aldosterone/renin or aldosterone/PRA favour the diagnosis.
Adrenal scanography (fine slices) has to be performed, and confronted with one functional procedure (adrenal iodocholestérol uptake after dexamethasone, or sampling of adrenal venous blood for aldosterone measurement) only if surgery is suggested.
When hypersecretion is unilateral or largely predominant in one size, surgery is very useful, when hypertension or hypokaliemia are poorly controlled, when medications are unwell tolerated, especially in men.
Primary hyperaldosteronism is a growing cause of apparently essential hypertension (until 15 % of patients with hypertension). Primary hyperaldosteronism can now be recognized even for patients ...without hypertension or hypokaliemia. Paradoxically normal levels of aldosterone when serum renin levels and/or plasmatic renin activity and/or kaliemia are low, lead to suggest primary hyperaldostéronism. High values of aldosterone/renin or aldosterone/PRA favour the diagnosis. Adrenal scanography (fine slices) has to be performed, and confronted with one functional procedure (adrenal iodocholestérol uptake after dexamethasone, or sampling of adrenal venous blood for aldosterone measurement) only if surgery is suggested. When hypersecretion is unilateral or largely predominant in one size, surgery is very useful, when hypertension or hypokaliemia are poorly controlled, when medications are unwell tolerated, especially in men.
Most abnormal parathyroid glands can be removed through the neck, but those deep in the chest have required sternotomy or thoracotomy. To avoid the morbidity of these open procedures, ectopic ...parathyroid glands deep in the chest were removed with video-assisted thoracoscopy.
Two patients with persistent primary and two with persistent secondary hyperparathyroidism had technetium-thallium scintigraphy and computed tomography of the chest to localize their ectopic glands. Video-assisted thoracoscopy was used for operative removal of these glands in each patient.
Parathyroid scans identified a mediastinal gland that was confirmed and localized precisely by the computed tomography scan. An enlarged ectopic gland weighing 1 to 2 gm was removed from each patient with normalization of serum calcium level. Glands were found by the main pulmonary artery, aortopulmonary window, ascending aorta, and aortic arch. One patient had recurrent disease 9 months later.
Removal of parathyroid glands deep in the chest with video-assisted thoracoscopy is a safe and successful alternative to median sternotomy.
Background: Despite abundant literature on parathyroid scanning with technetium 99m-labeled cationic complexes, comprehensive clinical reports that unequivocally correlate scanning findings with the ...anatomy of parathyroid glands in extensive and homogenous cohorts of patients are lacking.
Methods: We analyzed the records of patients with sporadic primary hyperparathyroidism who had had a preoperative scan with either
99mTc-labeled sestamibi or
99mTc-labeled tetrofosmin at our institution and who were cured after a bilateral surgical neck exploration procedure.
Results: In 261 patients, 710 normal and 347 abnormal glands (1494 ± 2626 mg), including 15 glands within the mediastinum, were identified. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of scanning were 82%, 98%, 91%, 94%, and 94%, respectively, in 197 patients with uniglandular disease and 53%, 98%, 98%, 60%, and 72%, respectively, in 64 patients with multiglandular disease. False-positive uptakes were encountered in 17 patients (7%), 3 false-positive uptakes being within the mediastinum. If the unilateral approach had been followed, guidance with preoperative scanning would have significantly increased the number of effective unilateral neck exploration procedures (164 patients (63%) vs 78 patients (30%);
P < .001). One abnormal gland would also have been neglected in 28 patients (11%).
Conclusions: Preoperative scanning would limit neck exploration procedures in two thirds of patients with sporadic primary hyperparathyroidism but may also increase the risk of failure in the most challenging cases. (Surgery 1999:126:1123-31.)
Background 18-F-fluoro-2-deoxyglucose positron emission tomography (18 FDG-PET) is useful in the detection of iodine-negative differentiated thyroid carcinoma (DTC). The aim of this prospective study ...was to assess therapeutic impact of18 FDG-PET imaging using a PET/computed tomography (CT) system in patients with iodine-negative recurrence of DTC. Methods From 2002 to 2006, patients with recurrence of DTC diagnosed by elevated thyroglobulin level and negative 131-I whole-body scan were included. Results Forty-five patients (31 women, 14 men), with a mean age of 55 years, with 36 papillary, 5 follicular, and 4 Hürthle carcinomas, were studied. All patients had previously undergone total thyroidectomy and postoperative thyroid remnant ablation with 131-I. The findings of18 FDG-PET/CT were positive in 31 patients (68.8%) and negative in 14 (32.2%). Results were true positive in 24 of 31 patients. The sensitivity, positive predictive value, and accuracy of18 FDG-PET/CT were 63%, 77%, and 53%, respectively. Twenty patients were operated on, 19 had neck surgery with mediastinal lymph node dissection (1 case) and lung resection (1 case), and 1 underwent lung resection. Seven patients had a stimulated thyroglobulin level <1 ng/mL. Conclusion18 FDG-PET/CT is able to select patients who can benefit from surgery. Normalization of thyroglobulin is observed in one third of operated patients.
The aim of this study was to assess the late outcome of patients with primary hyperparathyroidism and multiple gland enlargement (MGE) treated by conservative surgery. MGE in primary ...hyperparathyroidism is the presence of two or more enlarged glands weighing more than 50 mg. Conservative surgery consists in resecting the grossly enlarged glands without biopsying the normal glands. Some authors have suggested that this approach overlooks minute hyperplasia, leading to late recurrences of hyperparathyroidism; conversely, it may result in the unnecessary resection of grossly enlarged, but not hyperfunctioning, glands. Altogether 1231 patients were operated on for primary hyperparathyroidism between 1966 and 1995. Of these patients, 304 (24.9%) had MGE, including 42 cases of multiple endocrine neoplasia (MEN), 12 familial cases, and 250 seemingly sporadic cases. Two, three, or four glands (or more) were involved in 61.8%, 21.4%, and 16.4% of cases, respectively. During the early postoperative period one patient died and ten were reoperated for persistent hypercalcemia. The pathologic diagnoses were double adenomas (13.5%), hyperplasia (35.8%), association of the two (39.8%), and a normal second gland (10.8%) on light microscopy findings. None of the 30 deaths that occurred during follow‐up was related to hyperparathyroidism. Altogether 190 patients (79%) were available for follow‐up (average 89.3 months): 90% were normocalcemic, 4.7% hypocalcemic, and 5.2% hypercalcemic. A late iPTH assay was done in 147. PTH was appropriate to the serum calcium level in 84.3% and appropriate to normal calcemia in 91.6% of 132 cases. Conservative surgery is thus an acceptable treatment for MGE in patients with hyperparathyroidism. Few late recurrences occur, for which there are no individual predictive criteria.
Adrenocortical carcinomas are rare tumors. In the absence of the gold standard that constitutes metastases, local invasion or recurrence, the diagnosis of malignancy may represent a great challenge ...for both clinicians and pathologists. Several multiparametric systems have been developed to assess this malignancy. Among them, the Weiss system, established in 1984 and based on nine microscopic criteria, appears to be the most employed because of its simplicity and reliability. The presence of three and more criteria is in favor of malignancy. However, the application of such system is not devoid of difficulties and subjectivity. A more precise definition of the different microscopic criteria and the proposition of a modified Weiss system based on the most reliable criteria could help. Besides, the Weiss system is of limited value for the diagnosis of malignancy in oxyphil tumors and children tumors of the adrenal cortex.
