Le pseudomyxome péritonéal est une entité clinique caractérisée par une ascite gélatineuse associée à des dépôts mucineux disséminés sur le péritoine et. - digestif - Mucocèle appendiculaire et pseudomyxome péritonéal - EM| consulte. Access to the PDF text . L'adénomucinose péritonéale disséminée ( AMPD) correspond à une ascite essentiellement constituée de .. L'ascite gélatineuse, épaisse, et les implants nodulaires péritonéaux peuvent réaliser une. Request PDF on ResearchGate | La maladie gélatineuse du péritoine | Pseudomyxoma peritonei or gelatinous ascites is a rare clinical entity, and its.
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Request PDF on ResearchGate | Pseudomyxome péritonéal ou maladie gélatineuse du péritoine: nouveaux concepts et nouvelle prise en charge. 19 févr. Pseudomyxome ou maladie gélatineuse du péritoine. avec la présence d' une ascite, d'une infiltration du mésentère, et parfois de masses. gelatinous ascites. Cassagneau E. La maladie gélatineuse du péritoine. pelvic ultrasound finds a gelatinous ascites which has been.
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Next Pfizer aricept sales. Cancer Res 68, Cancer Res 51, Cancer Res 66, Krasilnikov MA Phosphatidylinositol-3 kinase dependent pathways: the role in control of cell growth, survival, and malignant transformation. Biochemistry Mosc 65, Cancer Res 57, Mol Cancer Ther 1, Discussion Treatment of metastatic breast cancer has currently many options.
Patients who harbor tumors positive for Her2neu, have great benefit with the use of Trastuzumab, combined with chemotherapy and as maintenance treatment. Primary resistance to Trastuzumag is challenging, and the prognosis of these patiens is poor. Lapatinig is a modern TKI that has the capacity of inhibition of EGFR1 and Her2neu, is authorized to treat metastatic breast cancer patients who progress after Trastuzumab, in combination with capecitabine.
There are many clinical trials currently exploring the combination of Lapatinib with different chemotherapeutics and hormone treatments. Gemcitabine is an active drug for the treatment of breast cancer.
Its toxic profile is considered to be safe, what allows for combination with a wide range of agents.
Gemcitabine is not cross resistant with taxanes or anthracyclines. Taking in consideration the reluctancy of our patient to take so many tablets, we considered this combination as potentially reasonable for our patient.
Results obtained are challenging, taking in consideration the immediate tumor growth after two cycles of maintenance therapy with Trastuzumab, and the proximity to the surgery. All of these facts reflect the existence of a primary resistance to Trastuzumab harbored by the tumor that we were treating. We cannot correlate the response observed in this case with the moderate expression of EGFR, as has been published Smylie et al, ; Gilmer et al, , but for us, this conclusion is tempting.
The occurrence of a complete response happened only in one patient treated with Lapatinib and Capecitabine in the most important Lapatinib clinical trial published to date and that was used as the basis for the approval of Lapatinib by the Food and Drug Administration Geyer et al, It is also anecdotal, in patients treated with Gemcitabine monotherapy. Our patient is to our knowledge, the first patient treated with a combination of these two drugs, considering that our patient had a primary resistance to Trastuzumab, the result obtained is exciting.
We cannot exclude the existence of a synergistic effect, although we are not able to investigate it. In view of this result, we can conclude that the combination of Gemcitabine and Lapatinib deserves future consideration in basic research, conducted within clinical trials and which look for potential synergies. Acknowledgments We would like to thank Francisco Sanchez Garcia for linguistic advice and revision.
Oncology 62, Cancer Res 64, The introduction of high resolution imaging and positron emission tomography has raised questions regarding the management of incidentally identified nodules and glucose avid carcinoma. This review is designed to address the contemporary approach to the management of thyroid cancer and discuss the controversies associated with initial management and recurrent disease.
Less commonly it may present as a lateral neck mass Hay, Thyroid cancer may present as a dominant nodule in a multinodular gland or as a solitary nodule. It was previously thought that the risk of malignancy was lower in a multinodular gland, but it is now recognized that the risk per gland is equivalent Tollin et al, and that incidentally discovered nodules carry a similar risk of malignancy Liebeskind et al, What this suggests is that any nodule may represent a cancer, and that every nodule should be evaluated.
Upon initial presentation, a careful history is essential because it can reveal information that immediately stratifies a patient into a high risk category. Introduction Thyroid carcinoma is a result of activation of several ill defined protooncogenes and defects related to a tumor suppressor gene.
Malignant transformation occurs most commonly in the follicular cell population resulting in well-differentiated carcinoma however it may also occur in the parafollicular cell or c- cell population resulting in poorly differentiated carcinoma. The dramatic increase in the rate of newly diagnosed thyroid cancers is likely a result of the improvement in imaging including high resolution ultrasound HUS , positron emission tomography PET , magnetic resonance imaging MRI and computed tomography CT.
While more than 25, people in the United States will be diagnosed with thyroid cancer next year, only will die from the disease. Evaluation of the thyroid nodule Thyroid carcinoma usually presents as a palpable thyroid nodule or a nodule that is discovered incidentally 7 Genden and Brett: Contemporary management of thyroid carcinoma accident Tronko et al, , and a family history of thyroid cancer.
The risk of thyroid cancer in first degree relatives of patients with differentiated thyroid cancer has been shown to be six times that of the general population Handkiewcz-Junak et al, Other important high risk factors include a history of rapid growth of a solid nodule, pain, dysphagia, or dysphonia. To most accurately determine the risk of malignancy, it is essential to consider a variety of factors Table 1.
There is no single laboratory study that is able to determine the presence of thyroid malignancy. Calcitonin levels are usually reserved for high risk patients and those with a family history of medullary thyroid carcinoma or multiple endocrine neoplasia MEN.
Thyroglobulin is not useful in the work up because there are a variety of conditions that can lead to elevated levels including thyroid inflammation, glandular stimulation or injury following radiation, surgery, or even a biopsy.
TSH should be measured to exclude a toxic nodule, as toxic nodules are almost never malignant and generally do not require fine needle aspiration. If the TSH is suppressed, then radioisotope imaging should be performed to confirm and localize the toxic nodule s. Generally, no additional imaging is required although CT and MRI scanning can sometimes be helpful in assessing presence of a substernal component of the gland or in pre-operative planning in cases where there is suspicion of laryngeal, tracheal, or esophageal invasion.
Once a suspicious nodule has been identified, ultrasound guided fine needle aspiration should be performed. Determining which nodules should be aspirated and whether there should be a size cut-off, has been a heavily debated topic largely because microscopic tumors are generally less aggressive Burman, The FNA has been demonstrated as the a highly sensitive method for identifying malignancy Mandell et al, and the diagnostic information that a FNA provides has been successful in decreasing the number of thyroidectomies while increasing the yield of malignancies in patients who undergo thyroidectomy Sidawy et al, The FNA may yield one of four possible diagnoses: Malignant disease, benign disease, suspicious for malignancy, or non-diagnostic.
Malignant lesions on FNA Table 1. Risk factors for thyroid carcinoma A. Role of ultrasound and ultrasoundguided fine needle aspiration History of radiation exposure Family history of papillary thyroid carcinoma Single dominant solid nodule greater than 4 cm. Male gender Rapid growth of a nodule Younger than 20 years old Older than 70 years old In contrast to other malignancies of the head and neck, the physical exam may not always be a strong predictor of malignancy Hay and Klee, Rare characteristics such as attachment to overlying skin and muscle, vocal cord paralysis, firmness to palpation, and the presence of lymphadenopathy, may raise the suspicion of a malignancy however, the majority of welldifferentiated thyroid cancers will present with subtle findings that may only be identified on imaging or cytology.
High resolution ultrasonography HUS offers the most sensitive and cost effective method for detecting a thyroid carcinoma Reading and Gorman, ; Grebe and Hay, ; Krishnamurthy et al, Using a 10 to 13 MHz transducer, nodules as small as 2mm can be clearly identified and evaluated. Table 2. Ultrasonographic characteristics suggestive of malignancy include hypoechogenicity, ill-defined margins, irregular borders, heterogeneity, and presence of calcification, particularly microcalcifications. Using these criteria, the sensitivity of ultrasound has been demonstrated as high as In the event that the FNA reveals a benign diagnosis, observation with repeat ultrasound in six months is generally appropriate.
Levothyroxine suppression therapy is no longer recommended. In the event that there is an increase in size of the nodule, the FNA should be repeated or the patient should be managed with a hemithyroidectomy.
A single repeat FNA for a previously benign aspirate will increase the sensitivity for malignancy from In the event that the FNA reveals a suspicious diagnosis, a hemithyroidectomy with frozen section pathologic analysis is recommended. Based on the intraoperative frozen section, the decision to complete the thyroidectomy or terminate the operation can be made. We offer patients with bilateral nodules and a suspicious aspirate the option of total thyroidectomy initially to avoid the possibility of requiring completion thyroidectomy or continued monitoring of the contralateral lobe.
In these cases, the decision making is more difficult. The FNA cannot differentiate a follicular carcinoma or Hurtle cell carcinoma from an adenoma because angioinvasion and invasion of the capsule can not be detected on cytology. If observation is elected, the nodule should be followed closely with ultrasound. In one recent study, ultrasound detection of nodes altered the surgical procedure in Ultrasound has also been shown to be highly sensitive and specific for detecting tracheal invasion by papillary thyroid cancer, which may be important in preoperative planning Tomoda et al, Clinical staging and risk group classification To effectively treat a malignancy of the thyroid gland it is essential to understand and document the behavior of the tumor.
Clinical staging and risk group classification is particularly important in the management of thyroid cancer because it often will direct management, in particular the decision to treat the patient with radioactive iodine, external beam radiation, or combination therapy.
The lack of prospective randomized studies assessing the relationships between tumor stage, treatment, and outcome, means that the majority of data that is used to create risk- group classifications is derived from retrospective reviews. As a result, there are variety of classification systems that are based on factors such as age, tumor size, gender, tumor grade, multicentricity, metastatic disease, and other variables.
Most of these classification systems utilize similar information with minor variations. Irrespective of the classification system that is used, it is important to consider risk group stratification during the management of a patient with thyroid cancer. Separate from these stratification systems is the TNM tumor staging system endorsed by the American Joint Committee on Cancer AJCC Table 5 which serves to provide a uniform language when evaluating management and outcome.
Preoperative evaluation The preoperative evaluation of a patient with suspected thyroid cancer should include a complete physical examination and a direct examination of the larynx to assess vocal fold motion.
Pre-operative ultrasound of the neck for patients with cytology suspicious for malignancy can be useful in identifying non-palpable lymph nodes and should routinely be Table 3. Wellcarcinoma differentiated cancers Hundahl et al, Table 6. PTC is derived from the follicular cells. These cells tend to concentrate iodine and secrete thyroglobulin. As a result, surveillance and detection of recurrence can be relatively straightforward.
The prognosis for PTC is usually excellent.
Papillary thyroid carcinoma Papillary thyroid carcinoma PTC is the most common form of the follicular cell derived carcinomas and comprises three quarters of all newly diagnosed thyroid 10 Cancer Therapy Vol 7, page 11 Table 6. New thyroid tumors by histological group. Management carcinoma papillary thyroid exists in the low risk patient sub-group.
Several studies have failed to demonstrate that low risk patients experience an improvement in cause-specific mortality after undergoing a total thyroidectomy Hay et al, , while several large studies have demonstrated that there is a benefit to total thyroidectomy Hay et al, ; Sanders and Cady, The conflicting data can make the decision-making process a difficult one. As a result, not all surgeons favor such guidelines and many prefer to perform a total thyroidectomy in spite of the risk stratification suggesting that the rate of morbidity in the hands of an experienced surgeon is exceedingly low Clark et al, To support this contention, a recent study found that surgeons who perform more than thyroidectomies per year reported complication rates of 4.
In spite of the complication rate, when a sub-total thyroidectomy is performed for the management of thyroid carcinoma, it becomes difficult to follow thyroglobulin levels for surveillance Inabnet, This may represent the most compelling argument to perform a total thyroidectomy for malignancy. Finally, the American Thyroid Association recently recommended that a total thyroidectomy should be performed for the management of well- differentiated thyroid carcinoma Sidawy et al, Surgery is the primary treatment for papillary thyroid cancer and a complete resection offers the best chance of cure Nishida et al, ; Thyroid Carcinoma Task Force, While the role of a complete surgical resection is indisputable, the extent of the initial surgical resection has been topic of controversy.
Primary management of thyroid malignancy has included nodulectomy, hemithyroidectomy with and without isthmusectomy, subtotal thyroidectomy, and total thyroidectomy. The high rate of recurrence associated with nodulectomy has confirmed that this approach is inadequate.
While there has been a trend toward more aggressive surgical resection based on the well-documented multicentric nature of the disease, there are still some who insist that a partial thyroidectomy is sufficient Shah et al, Opponents of total thyroidectomy suggest that multicentric bilateral disease is often microscopic and not clinically significant. This is further supported by the observation that several large studies have failed to demonstrate a survival advantage to total thyroidectomy when compared with hemithyroidectomy Rossi et al, ; Sanders and Cady, In spite of these findings, most clinicians agree that there is a subset of patients who benefit from total thyroidectomy while there is another distinct subset of patients that may be treated more conservatively.
Most surgeons agree with the recommendation to perform a total thyroidectomy when faced with a high risk patient. However the controversy B. Follicular thyroid carcinoma Follicular carcinoma is less common than papillary thyroid carcinoma Hundahl et al, and typically behaves more aggressively than papillary thyroid carcinoma. The aggressive nature of follicular thyroid carcinoma is largely a result of its propensity for hematogenous dissemination.
Unlike papillary thyroid carcinoma, which spreads through lymphatics, follicular carcinoma has a tendency to metastasize hematogenously to the lung and bones. As a result, a bony lesion or pathologic fracture may represent the initial presentation. The key to effective management of follicular carcinoma is making an early diagnosis and total thyroidectomy.
The rate of occult regional metastasis in papillary thyroid carcinoma is relatively high however occult metastasis in follicular carcinoma is rare. Hence, in patients with follicular carcinoma, an elective lymph node dissection is not commonly performed in the N0 neck.
If lymphadenopathy is detected, a paratracheal and pretracheal central compartment neck dissection should be performed. In papillary thyroid carcinoma, the high rate of paratracheal disease constitutes an ipsilateral paratracheal neck dissection when there is clinical evidence of disease. Node plucking is not acceptable as the rate likelihood of recurrence is exceedingly high Goldman et al, The definitive diagnosis of follicular thyroid carcinoma can be made only on permanent section.
Once the diagnosis of follicular carcinoma has been confirmed, the decision to proceed with a completion thyroidectomy or follow the patient is based on a variety of factors including risk group analysis.
Most agree that high risk patients require a total thyroidectomy. Not only does a total thyroidectomy improve prognosis but it is very helpful in achieving accurate surveillance by facilitating RAI administration and thyroglobulin monitoring.
There is controversy regarding the low risk group patients who present with minimally invasive lesions. The decision to perform a completion thyroidectomy is often based on age of the patient and invasiveness of the tumor. In patients greater than 50 years old or those with extensive invasion, we recommend a completion thyroidectomy. Patients with low grade tumors, tumors that demonstrate minimal invasion, can be managed conservatively with observation and serial ultrasound examination.
Minimally invasive follicular thyroid carcinoma tends to behave like a follicular adenoma. There is a very low incidence of metastasis in low grade follicular carcinoma Young et al, ; van Heerden et al, and unlike papillary thyroid carcinoma, minimally invasive lesions are rarely multifocal.
While some have advocated suppressive therapy for low risk patients, this approach has failed to demonstrate the benefit of suppressive therapy. Management of the N0 neck The approach to management of the N0 neck in papillary carcinoma has been a topic of controversy largely because there are few randomized, controlled, long term studies that demonstrate the impact of surgical treatment of the N0 neck. Currently, most surgeons perform a pretracheal and ipsilateral paratracheal lymph node dissection on high risk patients those patients aged 45 years or older, or patients with tumors greater than 4 cm, or invasive disease.
Only when the thyroid tumor crosses the midline is a contralateral lymph node dissection warranted. When a contralateral lymph node dissection is performed, the patient must be informed of the increased risk related to transient and permanent hypoparathyroidism Henry et al, As discussed earlier, in spite of the relatively high rate of documented skip metastasis, most surgeons do not advocate a lateral neck dissection.
The rationale for this approach stems from the lack of data demonstrating the benefit of a lateral neck dissection for subclinical disease and the prevailing belief that I can be used to manage microscopic lateral metastasis. Management of regional disease in welldifferentiated thyroid carcinoma Unlike squamous cell carcinoma, the impact of lymph node metastasis from thyroid cancer on survival is negligible, at least in the younger population. Several studies have suggested that lymph node metastasis may not impact survival Carcangiu et al, ; Noguchi et al, however when adjusted for age, it is clear that although regional disease does not significantly impact on survival in young patients, it does decrease survival in patients over the age of 45 Harwood et al, Long term studies have confirmed these observations and identified that in the population of patients over 45 years old, regional metastasis does impact survival Mazzaferri and Jhiang, As a result, most experts agree that clinically involved regional lymph nodes should be managed with a lymph node dissection.
There is, however, controversy regarding the impact of elective neck dissection on survival. This is largely a result of the paucity of controlled randomized studies. Thyroid cancer commonly progresses in a defined pathway from the first echelon lymph nodes of the 4. While only a small proportion of patients will initially present with a neck mass Shaha et al, , a significant number of patients will harbor subclinical paratracheal disease at the time of diagnosis.
The size of the primary thyroid tumor has little bearing on the extent or location of regional disease. Several groups including our own, have found that while large cancers of the thyroid may remain localized, microcarcinoma may present with extensive regional disease McConahey et al, As a result it is difficult to predict the risk of regional disease based on the size of the tumor and therefore every patient must be evaluated for regional metastasis.
I has not been demonstrated effective for management of gross regional disease Wilson and Bock, In the past, there was controversy regarding the extent of the dissection however most surgeons now advocate a selective neck dissection levels III, IV, and VI in which the jugular vein, sternocleidomastoid muscle, and the accessory nerve are preserved.
Although rare, when invasion of the surrounding structures occurs, a modified neck dissection may be warranted. Diagnosis of recurrent and distant disease Recurrent well-differentiated thyroid cancer is not uncommon. Since the volume of recurrent or distant metastatic disease correlates relatively well with the prognosis, early diagnosis and management is essential.
Whole body I scanning and should be performed in high risk patients 6 to 12 months after the primary surgery. Low risk patients can usually be evaluated by recombinant TSH Thyrogen stimulated thyroglobulin levels avoiding the need for an iodine scan. Since the majority of recurrences occur in the thyroid bed, neck ultrasonography represents the most sensitive means for detecting recurrence in the presence of elevated thyroglobulin.
Jadvar et al. All 3 patients had pathologic confirmation of recurrence, with Recent evidence suggests that PET- positive disease is unlikely to I and may be associated with a more biologically aggressive tumor McDonald et al, Radioiodine therapy Remnant ablation with I is routinely performed in all patients except for very low risk patients after total thyroidectomy to decrease the risk of recurrence and facilitate monitoring of thyroglobulin.
Thyroid replacement is discontinued and a low iodine diet instituted in an effort to increase the avidity of the residual thyroid tissue.
Patients in whom residual microscopic disease is suspected and those with more aggressive tumor histology or known distant metastasis are administered higher doses of I in the range of to mCi. Younger patients with iodine avid tumors tend have a favorable response to I.
The response of pulmonary metastasis to I is predicated on the size of the lesion, the age of the patient, and its ability to concentrate I Casara et al, ; Schlumberger et al, In contrast, bone metastases, which occur more commonly in follicular thyroid carcinoma, are less responsive to therapy.