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Reimondo G, Muller A, Ingargiola E, Puglisi S, Terzolo M. Is Follow-up of Adrenal Incidentalomas Always Mandatory? Endocrinol Metab (Seoul) 2020; 35:26-35. [PMID: 32207261 PMCID: PMC7090287 DOI: 10.3803/enm.2020.35.1.26] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Revised: 01/24/2020] [Accepted: 01/31/2020] [Indexed: 12/11/2022] Open
Abstract
Adrenal masses are mainly detected unexpectedly by an imaging study performed for reasons unrelated to any suspect of adrenal diseases. Such masses are commonly defined as "adrenal incidentalomas" and represent a public health challenge because they are increasingly recognized in current medical practice. Management of adrenal incidentalomas is currently matter of debate. Although there is consensus on the need of a multidisciplinary expert team evaluation and surgical approach in patients with significant hormonal excess and/or radiological findings suspicious of malignancy demonstrated at the diagnosis or during follow-up, the inconsistency between official guidelines and the consequent diffuse uncertainty on management of small adrenal incidentalomas still represents a considerable problem in terms of clinical choices in real practice. The aim of the present work is to review the proposed strategies on how to manage patients with adrenal incidentalomas that are not candidates to immediate surgery. The recent European Society of Endocrinology/European Network for the Study of Adrenal Tumors guidelines have supported the view to avoid surveillance in patients with clear benign adrenal lesions <4 cm and/or without any hormonal secretion; however, newer prospective studies are needed to confirm safety of this strategy, in particular in younger patients.
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Affiliation(s)
- Giuseppe Reimondo
- Division of Internal Medicine, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy
| | - Alessandra Muller
- Division of Internal Medicine, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy
| | - Elisa Ingargiola
- Division of Internal Medicine, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy
| | - Soraya Puglisi
- Division of Internal Medicine, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy.
| | - Massimo Terzolo
- Division of Internal Medicine, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy
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Chiloiro S, Giampietro A, Raffaelli M, D'Amato G, Bima C, Lauretti L, Anile C, Lombardi CP, Rindi G, Bellantone R, De Marinis L, Pontecorvi A, Bianchi A. Synchronous bilateral adrenalectomy in ACTH-dependent hypercortisolism: predictors, biomarkers and outcomes. Endocrine 2019; 66:642-649. [PMID: 31583577 DOI: 10.1007/s12020-019-02091-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 09/13/2019] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Hypercortisolism requires a prompt therapeutic management to reduce the risk of development of a potential fatal emergency. A synchronous bilateral adrenalectomy (SBA) is effective in recovering hypercortisolism. However, specific indications for an SBA are not available. We aimed to evaluate the outcome of patients who underwent an SBA and to identify biomarkers able to predict the requirements of an SBA. PATIENTS AND METHODS A mono-centric and longitudinal study was conducted on 19 consecutive patients who underwent SBA for ACTH-dependent hypercortisolism between December 2003 and December 2017. This study population was compared to two control groups composed of patients cured after the resection of the ACTH secreting pituitary adenoma (Group A: 44 patients) and of the ACTH-secreting neuroendocrine tumours (Group B: 8 patients). RESULTS Short- or long-term SBA complications or the recurrence of hypercortisolism did not occur. A single patient experienced Nelson syndrome. Clinical features after SBA showed improvement in the glico-metabolic assessment, hypertension, bone metabolism and the occurrence of hypokalaemia and infections. The younger the age at the time of Cushing's disease diagnosis, the longer the duration of active hypercortisolism, higher values of plasmatic ACTH and Cortisol (1 month after pituitary neurosurgery) and higher values of Ki67 in pituitary adenomas were detected in this study population as compared to Group A. CONCLUSIONS SBA is an effective and safe treatment for patients with unmanageable ACTH-dependent hypercortisolism. A multidisciplinary team in a referral centre with a high volume of patients is strongly recommended for the management of these patients and the identification of patients, for better surgical timing.
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Affiliation(s)
- S Chiloiro
- Pituitary Unit, Divisione di Endocrinologia, Fondazione Policlinico Universitario A. Gemelli IRCCS - Università Cattolica del Sacro Cuore, 00168, Roma, Italy
| | - A Giampietro
- Pituitary Unit, Divisione di Endocrinologia, Fondazione Policlinico Universitario A. Gemelli IRCCS - Università Cattolica del Sacro Cuore, 00168, Roma, Italy
| | - M Raffaelli
- Department of Endocrine and Metabolic Surgery, Fondazione Policlinico Universitario A. Gemelli IRCCS - Università Cattolica del Sacro Cuore, 00168, Roma, Italy
| | - G D'Amato
- Department of Endocrine and Metabolic Surgery, Fondazione Policlinico Universitario A. Gemelli IRCCS - Università Cattolica del Sacro Cuore, 00168, Roma, Italy
| | - C Bima
- Pituitary Unit, Divisione di Endocrinologia, Fondazione Policlinico Universitario A. Gemelli IRCCS - Università Cattolica del Sacro Cuore, 00168, Roma, Italy
| | - L Lauretti
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS - Università Cattolica del Sacro Cuore, 00168, Roma, Italy
| | - C Anile
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS - Università Cattolica del Sacro Cuore, 00168, Roma, Italy
| | - C P Lombardi
- Department of Endocrine and Metabolic Surgery, Fondazione Policlinico Universitario A. Gemelli IRCCS - Università Cattolica del Sacro Cuore, 00168, Roma, Italy
| | - G Rindi
- Department of Pathology, Fondazione Policlinico Universitario A. Gemelli IRCCS Catholic University Rome, Rome, Italy
| | - R Bellantone
- Department of Endocrine and Metabolic Surgery, Fondazione Policlinico Universitario A. Gemelli IRCCS - Università Cattolica del Sacro Cuore, 00168, Roma, Italy
| | - L De Marinis
- Pituitary Unit, Divisione di Endocrinologia, Fondazione Policlinico Universitario A. Gemelli IRCCS - Università Cattolica del Sacro Cuore, 00168, Roma, Italy.
| | - A Pontecorvi
- Pituitary Unit, Divisione di Endocrinologia, Fondazione Policlinico Universitario A. Gemelli IRCCS - Università Cattolica del Sacro Cuore, 00168, Roma, Italy
| | - A Bianchi
- Pituitary Unit, Divisione di Endocrinologia, Fondazione Policlinico Universitario A. Gemelli IRCCS - Università Cattolica del Sacro Cuore, 00168, Roma, Italy
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Knoble N, Nayroles G, Cheng C, Arnould B. Illustration of patient-reported outcome challenges and solutions in rare diseases: a systematic review in Cushing's syndrome. Orphanet J Rare Dis 2018; 13:228. [PMID: 30567582 PMCID: PMC6299940 DOI: 10.1186/s13023-018-0958-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Accepted: 11/20/2018] [Indexed: 12/15/2022] Open
Abstract
Rare diseases are often not fully understood and efforts put in investigating it from patient perspective are usually met with challenges. We performed a systematic literature review (SLR) for the last 20 years in Cushing's Syndrome (CS) to illustrate Patient-Reported Outcome (PRO) challenges, and show what solutions were found.PROs and other Clinical Outcome Assessment (COA) used with CS patients were reviewed in 36 studies. Two CS-specific Health Related Quality of Life (HRQL) measures were identified (i.e., CushingQoL, Tuebingen CD-25), as well as depression and neurocognitive measures. For CS-specific HRQL measures, the CushingQoL was the most widely used measure due in part to being the first CS-specific HRQL measure developed. With algorithms mapping the CushingQoL to both the SF-6D and EQ-5D, the CushingQoL could be used to facilitate economic modelling studies in the absence of a generic HRQL measure. While the CushingQoL offers only the global scale and two subscales compared to the six subscales of the Tuebingen CD-25, there is not yet adequate statistical validation data available for the Tuebingen CD-25 to suggest it can withstand the scrutiny of review by multiple stakeholders. Results of this review indicate that the inclusion of a measure of depressive symptoms, such as the BDI-II or similar measure, would be reasonable to include given the high level of comorbidity of depression among CS patients. A brief neurocognitive performance outcome, such as Trail Making tasks A and D or Digit Symbol, could help inform the interpretation of HRQL results. Neurocognitive differences may be an unassessed mediator of HRQL outcomes, partly accounting for the persistence of depressive symptoms and HRQL deficits despite treatment. Results suggest that HRQL improvements are possible within this population. These results are limited by small sample sizes and pre/post study design.CS showcases the difficulties encountered in measuring PROs in rare diseases. A solution for this specific case was developed in the form of dedicated PRO instruments, the CushingQOL and the Tuebingen-25. However, some aspects of CS may not be fully answered or not yet validated (e.g., depressive and cognitive symptoms). Further research needs to be done to address them.
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Affiliation(s)
- Naomi Knoble
- Mapi, an ICON plc Company, 27 rue de la Villette, 69003 Lyon, France
| | | | - Cherry Cheng
- Ipsen Pharma, 65 quai Georges Gorse, 92560 Boulogne-Billancourt, France
| | - Benoit Arnould
- Mapi, an ICON plc Company, 27 rue de la Villette, 69003 Lyon, France
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Babic B, De Roulet A, Volpe A, Nilubol N. Is VTE Prophylaxis Necessary on Discharge for Patients Undergoing Adrenalectomy for Cushing Syndrome? J Endocr Soc 2018; 3:304-313. [PMID: 30652131 PMCID: PMC6330172 DOI: 10.1210/js.2018-00278] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 12/07/2018] [Indexed: 11/19/2022] Open
Abstract
Background Patients with Cushing syndrome (CS) have an increased risk for venous thromboembolism (VTE). However, it is unclear whether patients undergoing adrenalectomy for CS are at increased risk for postoperative VTE. The aim of this study was to determine the rate of postoperative VTE in patients undergoing adrenalectomy for CS. Methods A retrospective analysis of patients in the American College of Surgeons National Surgical Quality Improvement Program database who underwent adrenalectomy from 2005 to 2016 was performed. We compared the clinical characteristics and 30-day postoperative VTE occurrence in patients with and without CS. Results A total of 4217 patients were analyzed; 2607 (61.8%) were female and 310 (7.4%) had CS. The overall prevalence of postoperative VTE was 1.0% (n = 45). The rates of VTE were higher in patients with CS (2.6% vs 0.9%; P = 0.007). In the two groups, CS was associated with younger age, increased body mass index, and diabetes mellitus (P < 0.001). CS was also associated with longer length of operation and longer hospital length of stay (P < 0.001). In the subgroup of patients who had diagnosed VTE, CS was associated with longer length of operation (P < 0.001). Rates of laparoscopic vs open surgery were equivalent between patients with and without CS, and VTE events did not differ. The median time to VTE event was 14.5 days (range, 1 to 23 days) in the CS group and 4 days (range, 2 to 25 days) in the group without CS. Conclusions The prevalence of postoperative VTE was increased in patients undergoing adrenalectomy for CS. In patients with CS undergoing adrenalectomy, VTE prophylaxis for 28 days should be considered upon discharge.
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Affiliation(s)
- Bruna Babic
- Department of Surgery, New York Presbyterian-Queens, Flushing, New York
| | - Amory De Roulet
- Department of Surgery, New York Presbyterian-Queens, Flushing, New York
| | - Anita Volpe
- Department of Surgery, New York Presbyterian-Queens, Flushing, New York
| | - Naris Nilubol
- Endocrine Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
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Fassnacht M, Arlt W, Bancos I, Dralle H, Newell-Price J, Sahdev A, Tabarin A, Terzolo M, Tsagarakis S, Dekkers OM. Management of adrenal incidentalomas: European Society of Endocrinology Clinical Practice Guideline in collaboration with the European Network for the Study of Adrenal Tumors. Eur J Endocrinol 2016; 175:G1-G34. [PMID: 27390021 DOI: 10.1530/eje-16-0467] [Citation(s) in RCA: 936] [Impact Index Per Article: 117.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Accepted: 06/02/2016] [Indexed: 12/13/2022]
Abstract
: By definition, an adrenal incidentaloma is an asymptomatic adrenal mass detected on imaging not performed for suspected adrenal disease. In most cases, adrenal incidentalomas are nonfunctioning adrenocortical adenomas, but may also represent conditions requiring therapeutic intervention (e.g. adrenocortical carcinoma, pheochromocytoma, hormone-producing adenoma or metastasis). The purpose of this guideline is to provide clinicians with best possible evidence-based recommendations for clinical management of patients with adrenal incidentalomas based on the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. We predefined four main clinical questions crucial for the management of adrenal incidentaloma patients, addressing these four with systematic literature searches: (A) How to assess risk of malignancy?; (B) How to define and manage low-level autonomous cortisol secretion, formerly called 'subclinical' Cushing's syndrome?; (C) Who should have surgical treatment and how should it be performed?; (D) What follow-up is indicated if the adrenal incidentaloma is not surgically removed? SELECTED RECOMMENDATIONS: (i) At the time of initial detection of an adrenal mass establishing whether the mass is benign or malignant is an important aim to avoid cumbersome and expensive follow-up imaging in those with benign disease. (ii) To exclude cortisol excess, a 1mg overnight dexamethasone suppression test should be performed (applying a cut-off value of serum cortisol ≤50nmol/L (1.8µg/dL)). (iii) For patients without clinical signs of overt Cushing's syndrome but serum cortisol levels post 1mg dexamethasone >138nmol/L (>5µg/dL), we propose the term 'autonomous cortisol secretion'. (iv) All patients with '(possible) autonomous cortisol' secretion should be screened for hypertension and type 2 diabetes mellitus, to ensure these are appropriately treated. (v) Surgical treatment should be considered in an individualized approach in patients with 'autonomous cortisol secretion' who also have comorbidities that are potentially related to cortisol excess. (vi) In principle, the appropriateness of surgical intervention should be guided by the likelihood of malignancy, the presence and degree of hormone excess, age, general health and patient preference. (vii) Surgery is not usually indicated in patients with an asymptomatic, nonfunctioning unilateral adrenal mass and obvious benign features on imaging studies. We provide guidance on which surgical approach should be considered for adrenal masses with radiological findings suspicious of malignancy. Furthermore, we offer recommendations for the follow-up of patients with adrenal incidentaloma who do not undergo adrenal surgery, for those with bilateral incidentalomas, for patients with extra-adrenal malignancy and adrenal masses and for young and elderly patients with adrenal incidentalomas.
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Affiliation(s)
- Martin Fassnacht
- Department of Internal Medicine IDivision of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany Comprehensive Cancer Center MainfrankenUniversity of Würzburg, Würzburg, Germany
| | - Wiebke Arlt
- Institute of Metabolism & Systems ResearchUniversity of Birmingham, Birmingham, UK Centre for EndocrinologyDiabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Irina Bancos
- Institute of Metabolism & Systems ResearchUniversity of Birmingham, Birmingham, UK Centre for EndocrinologyDiabetes and Metabolism, Birmingham Health Partners, Birmingham, UK Division of EndocrinologyMetabolism, Nutrition and Diabetes, Mayo Clinic, Rochester, Minnesota, USA
| | - Henning Dralle
- Department of GeneralVisceral, and Vascular Surgery, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - John Newell-Price
- Department of Oncology and MetabolismMedical School, University of Sheffield, Sheffield, UK Endocrine UnitRoyal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Anju Sahdev
- Department of ImagingSt Bartholomew's Hospital, Barts Health, London, UK
| | - Antoine Tabarin
- Department of Endocrinology and INSERM U862University and CHU of Bordeaux, Pessac, France
| | - Massimo Terzolo
- Internal Medicine 1Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Stylianos Tsagarakis
- Department of EndocrinologyDiabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Olaf M Dekkers
- Departments of Clinical Epidemiology and Internal MedicineLeiden University Medical Centre, Leiden, The Netherlands Department of Clinical EpidemiologyAarhus University, Aarhus, Denmark
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Guerin C, Taieb D, Treglia G, Brue T, Lacroix A, Sebag F, Castinetti F. Bilateral adrenalectomy in the 21st century: when to use it for hypercortisolism? Endocr Relat Cancer 2016; 23:R131-42. [PMID: 26739832 DOI: 10.1530/erc-15-0541] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Therapeutic options available for the treatment of Cushing's syndrome (CS) have expanded over the last 5 years. For instance, the efficient management of severe hypercortisolism using a combination of fast-acting steroidogenesis inhibitors has been reported. Recent publications on the long-term efficacy of drugs or radiation techniques have also demonstrated low toxicity. These data should encourage endocrinologists to reconsider the place of bilateral adrenalectomy in patients with ACTH-dependent aetiologies of CS; similarly, the indication of bilateral adrenalectomy is reassessed in primary bilateral macronodular adrenal hyperplasia. The objective of this review is to compare the efficacy and side effects of the various therapeutic options of hypercortisolism with those of bilateral adrenalectomy, in order to better define its indications in the 21st century.
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Affiliation(s)
- Carole Guerin
- Aix-Marseille UniversityAssistance Publique Hopitaux de Marseille, Department of Endocrine Surgery, La Conception Hospital, Marseille, FranceAix-Marseille UniversityAssistance Publique Hopitaux de Marseille, Department of Nuclear Medicine, La Timone Hospital, Marseille, FranceDepartment of Nuclear MedicineThyroid and PET/CT Center, Oncology Institute of Southern Switzerland, Bellinzona and Lugano, SwitzerlandAix-Marseille UniversityAssistance Publique Hopitaux de Marseille, Department of Endocrinology, La Conception Hospital, 147 Boulevard Baille, 13005 Marseille, FranceEndocrine DivisionDepartment of Medicine, Centre hospitalier de l'Université de Montréal (CHUM), Montreal, Canada
| | - David Taieb
- Aix-Marseille UniversityAssistance Publique Hopitaux de Marseille, Department of Endocrine Surgery, La Conception Hospital, Marseille, FranceAix-Marseille UniversityAssistance Publique Hopitaux de Marseille, Department of Nuclear Medicine, La Timone Hospital, Marseille, FranceDepartment of Nuclear MedicineThyroid and PET/CT Center, Oncology Institute of Southern Switzerland, Bellinzona and Lugano, SwitzerlandAix-Marseille UniversityAssistance Publique Hopitaux de Marseille, Department of Endocrinology, La Conception Hospital, 147 Boulevard Baille, 13005 Marseille, FranceEndocrine DivisionDepartment of Medicine, Centre hospitalier de l'Université de Montréal (CHUM), Montreal, Canada
| | - Giorgio Treglia
- Aix-Marseille UniversityAssistance Publique Hopitaux de Marseille, Department of Endocrine Surgery, La Conception Hospital, Marseille, FranceAix-Marseille UniversityAssistance Publique Hopitaux de Marseille, Department of Nuclear Medicine, La Timone Hospital, Marseille, FranceDepartment of Nuclear MedicineThyroid and PET/CT Center, Oncology Institute of Southern Switzerland, Bellinzona and Lugano, SwitzerlandAix-Marseille UniversityAssistance Publique Hopitaux de Marseille, Department of Endocrinology, La Conception Hospital, 147 Boulevard Baille, 13005 Marseille, FranceEndocrine DivisionDepartment of Medicine, Centre hospitalier de l'Université de Montréal (CHUM), Montreal, Canada
| | - Thierry Brue
- Aix-Marseille UniversityAssistance Publique Hopitaux de Marseille, Department of Endocrine Surgery, La Conception Hospital, Marseille, FranceAix-Marseille UniversityAssistance Publique Hopitaux de Marseille, Department of Nuclear Medicine, La Timone Hospital, Marseille, FranceDepartment of Nuclear MedicineThyroid and PET/CT Center, Oncology Institute of Southern Switzerland, Bellinzona and Lugano, SwitzerlandAix-Marseille UniversityAssistance Publique Hopitaux de Marseille, Department of Endocrinology, La Conception Hospital, 147 Boulevard Baille, 13005 Marseille, FranceEndocrine DivisionDepartment of Medicine, Centre hospitalier de l'Université de Montréal (CHUM), Montreal, Canada
| | - André Lacroix
- Aix-Marseille UniversityAssistance Publique Hopitaux de Marseille, Department of Endocrine Surgery, La Conception Hospital, Marseille, FranceAix-Marseille UniversityAssistance Publique Hopitaux de Marseille, Department of Nuclear Medicine, La Timone Hospital, Marseille, FranceDepartment of Nuclear MedicineThyroid and PET/CT Center, Oncology Institute of Southern Switzerland, Bellinzona and Lugano, SwitzerlandAix-Marseille UniversityAssistance Publique Hopitaux de Marseille, Department of Endocrinology, La Conception Hospital, 147 Boulevard Baille, 13005 Marseille, FranceEndocrine DivisionDepartment of Medicine, Centre hospitalier de l'Université de Montréal (CHUM), Montreal, Canada
| | - Frederic Sebag
- Aix-Marseille UniversityAssistance Publique Hopitaux de Marseille, Department of Endocrine Surgery, La Conception Hospital, Marseille, FranceAix-Marseille UniversityAssistance Publique Hopitaux de Marseille, Department of Nuclear Medicine, La Timone Hospital, Marseille, FranceDepartment of Nuclear MedicineThyroid and PET/CT Center, Oncology Institute of Southern Switzerland, Bellinzona and Lugano, SwitzerlandAix-Marseille UniversityAssistance Publique Hopitaux de Marseille, Department of Endocrinology, La Conception Hospital, 147 Boulevard Baille, 13005 Marseille, FranceEndocrine DivisionDepartment of Medicine, Centre hospitalier de l'Université de Montréal (CHUM), Montreal, Canada
| | - Frederic Castinetti
- Aix-Marseille UniversityAssistance Publique Hopitaux de Marseille, Department of Endocrine Surgery, La Conception Hospital, Marseille, FranceAix-Marseille UniversityAssistance Publique Hopitaux de Marseille, Department of Nuclear Medicine, La Timone Hospital, Marseille, FranceDepartment of Nuclear MedicineThyroid and PET/CT Center, Oncology Institute of Southern Switzerland, Bellinzona and Lugano, SwitzerlandAix-Marseille UniversityAssistance Publique Hopitaux de Marseille, Department of Endocrinology, La Conception Hospital, 147 Boulevard Baille, 13005 Marseille, FranceEndocrine DivisionDepartment of Medicine, Centre hospitalier de l'Université de Montréal (CHUM), Montreal, Canada
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