Somatostatin receptor imaging for the diagnosis and management of gastro-entero-pancreatic neuroendocrine tumors

This is a review of my work focusing on molecular diagnostic markers, as well as the staging and surgical management of gastro-entero-pancreatic neuroendocrine tumors (GEP-NETs). We prospectively studied the clinical utility of 68Ga-DOTATATE imaging in the detection of unknown primary tumors and metastatic disease in patients with suspected or known GEP-NETs, and compared it to that of the current FDA-approved imaging modalities such as 111In- pentetreotide single-photon emission computed tomography (SPECT/CT), computed tomography (CT), and/or magnetic resonance imaging (MRI). We found that 68Ga-DOTATATE PET/CT imaging was the most sensitive in the staging and detection of unknown primary GEP-NETs. These findings have opened new avenues for the diagnosis and treatment of GEP-NETs, as well as access to precision surgery, which combined with imaging and tumor genomics, represents the future in terms of the application of personalized cancer management

L'utilisation systématique du neuromonitoring du nerf laryngé récurrent modifie la stratégie opératoire en chirurgie thyroïdienne bilatérale

La complication la plus redoutée en chirurgie thyroïdienne est la paralysie du nerf laryngé récurrent (NLR) bilatérale, qui peut nécessiter une trachéostomie pour assurer la sécurité des voies aériennes. Depuis 2010 nous avons instauré un protocole chirurgical standardisé avec arrêt de la chirurgie du premier côté en cas de perte de signal sur le nerf vague lors d'opérations bilatérales. L'opération fut arrêtée dans 9 cas et la laryngoscopie démontrait une paralysie au premier jour chez 7 patients. Tous ont récupérés entre 1-4 mois et les cas de cancer ont été opérés du 2ième côté après 3 jours à 3 mois. Nous concluons que l'utilisation systématique du neuromonitoring avec une modification de la stratégie opératoire réduit le risque de paralysie du NLR bilatérale à 0%. Nous pensons qu'une perte de signal après le premier coté devrait mener à un arrêt de la procédure, ceci également en cas de pathologie maligne

Management of pancreatic neuroendocrine tumors in patients with MEN 1

Pancreatic neuroendocrine tumors (PNETs) are frequent and can be non-functional (NF) in patients with multiple endocrine neoplasia type 1 (MEN1). Their identification is of clinical importance because malignant PNETs are reported to be the most common cause of death in patients with MEN1. Once the diagnosis of MEN1 is established in an individual based on clinical manifestations and/or genetic testing results, an active surveillance program is instituted for early detection and treatment of MEN1-associated disease. Ultrasonography, endoscopic ultrasonography (EUS), CT, MRI, selective arterial angiography and somatostatin receptor scintigraphy are all used for localization of tumors. Managing PNETs can be challenging and includes diagnosis, surveillance, adequate staging, and interdisciplinary, multimodal treatments to optimize patient outcome. Treatment includes surgical resection for loco-regional disease, as well as liver directed and targeted chemotherapies for advanced progressive disease. To date, the recommendation for surgical resection in NF-PNETs is based on tumor size, as a higher rate of metastases was found in patients with larger tumors. This review summarizes key concepts in managing PNETs in patients with MEN1

A reappraisal of vascular anatomy of the parathyroid gland based on fluorescence techniques

Identification of the parathyroid glands (PGs) during thyroid surgery may prevent their inadvertent surgical removal and prevent postoperative hypoparathyroidism. However, identification of the PGs does not guarantee their function, and their vascular supply needs to be preserved as well. The recent introduction of intraoperative indocyanine green (ICG) fluorescent angiography of the PGs during thyroid surgery allows for the appraisal of the vascular anatomy and evaluation of PG function. The use of this tool could lead to a significant reduction in the rate of postoperative hypoparathyroidism, as it allows surgeons to adapt their surgical technique for the preservation of the PGs. ICG fluorescent angiography is currently the only available real-time tool to assess the vascular blood supply of each individual PG intraoperatively and can thus assist surgeons in their decision-making. Herein, we review the relevant literature

The future: surgical advances in MEN1 therapeutic approaches and management strategies

Multiple endocrine neoplasia type 1 (MEN1) is a hereditary autosomal dominant disorder associated with numerous neuroendocrine tumors (NETs). Recent advances in the management of MEN1 have led to a decrease in mortality due to excess hormones; however, they have also led to an increase in mortality from malignancy, particularly NETs. The main challenges are to localize these tumors, to select those that need therapy because of the risk of aggressive behavior, and to select the appropriate therapy associated with minimal morbidity. This must be applied to a hereditary disease with a high risk of recurrence. The overall aim of management in MEN1 is to ensure that the patient remains disease- and symptom-free for as long as possible and maintains a good quality of life. Herein, we review the changes that occurred in the last 20 years in the surgical management of MEN1-associated functional and non-functional pancreatico-duodenal NETs, and thymic and bronchial NETs

The search for preoperative biomarkers for thyroid carcinoma: application of the thyroid circadian clock properties

Accumulating evidence suggests that alterations in the molecular clocks underlying the circadian time-keeping system might be connected to changes in cell cycle, resulting in oncogenic transformation. The hypothalamic-pituitary-thyroid axis is driven by a circadian clock at several levels, with an endocrine feedback loop regulating thyroid-stimulating hormone. Changes in the expression levels of circadian and cell cycle markers may correlate with clinic-pathological characteristics in differentiated follicular thyroid carcinomas. Here we summarize recent advances in exploring complex regulation of the thyroid gland transcriptome and function by the circadian oscillator. We particularly focus on clinical implications of the parallel assessment of the circadian clock, cell-cycle and cell functionality markers in human thyroid tissue, which might help improving preoperative diagnostics of thyroid malignancies

Oncocytic Adrenocortical Neoplasm with Concomitant Papillary Thyroid Cancer

Adrenal oncocytoma (AO) is an extremely rare adrenocortical neoplasm and little is known about its malignant potential, secretory properties, and hereditary origin. We present the case of a benign AO with concomitant incidentally found papillary thyroid cancer (PTC) and review similar cases in the literature. Immunohistochemistry and next-generation sequencing (NGS) were performed. A 66-year-old women was incidentally found to have a large, androgen-secreting right adrenal mass. 18F-Fluorodeoxyglucose positron emission tomography showed intense uptake (SUVmax 88.7) of this mass and found a hypermetabolic right thyroid mass. Open adrenalectomy was performed for this highly suspicious adrenal mass. Histopathology revealed benign AO that was BRAFV600E negative, with low Ki-67, and no somatic mutation found on NGS. Thyroidectomy revealed invasive, BRAFV600E-positive PTC. At 6 months follow-up, androgen levels returned to normal, and no recurrence was seen on imaging. To our knowledge, this is the first report of an androgen-secreting AO with concomitant PTC. Possibly the simultaneous discovery of two independent neoplasms was observed. In conclusion, this case highlights that care should be given to exclude concomitant neoplasms. Long-term and regular imaging with biochemical follow-up is warranted, since the outcome and clinical behavior of AO remains uncertain

Systematic use of recurrent laryngeal nerve neuromonitoring changes the operative strategy in planned bilateral thyroidectomy

One of the worst complications in thyroid surgery is bilateral recurrent laryngeal nerve paralysis, which can lead to transient or definitive tracheotomy

Acute pancreatitis after thoracic duct ligation for iatrogenic chylothorax. A case report

To report the association between thoracic duct ligation and acute pancreatitis. The association between sudden stop of lymphatic flow and pancreatitis has been established in experimental models