Glucagon-like peptide-1 receptor imaging with [Lys40(Ahx-HYNIC- 99mTc/EDDA)NH2]-exendin-4 for the detection of insulinoma

PURPOSE

The objective of this article is to present a new method for the diagnosis of insulinoma with the use of [Lys(40)(Ahx-HYNIC-(99m)Tc/EDDA)NH2]-exendin-4.

METHODS

Studies were performed in 11 patients with negative results of all available non-isotopic diagnostic methods (8 with symptoms of insulinoma, 2 with malignant insulinoma and 1 with nesidioblastosis). In all patients glucagon-like peptide-1 (GLP-1) receptor imaging (whole-body and single photon emission computed tomography/CT examinations) after the injection of 740 MBq of the tracer was performed.

RESULTS

Both sensitivity and specificity of GLP-1 receptor imaging were assessed to be 100 % in patients with benign insulinoma. In all eight cases with suspicion of insulinoma a focal uptake in the pancreas was found. In six patients surgical excision of the tumour was performed (type G1 tumours were confirmed histopathologically). In one patient surgical treatment is planned. One patient was disqualified from surgery. In one case with malignant insulinoma pathological accumulation of the tracer was found only in the region of local recurrence. The GLP-1 study was negative in the other malignant insulinoma patient. In one case with suspicion of nesidioblastosis, a focal accumulation of the tracer was observed and histopathology revealed coexistence of insulinoma and nesidioblastosis.

CONCLUSION

[Lys(40)(Ahx-HYNIC-(99m)Tc/EDDA)NH2]-exendin-4 seems to be a promising diagnostic tool in the localization of small insulinoma tumours, but requires verification in a larger series of patients.

Current and future medical therapy, and the molecular features of adrenocortical cancer

Adrenocortical carcinoma (ACC) is a rare neoplasm with very poor prognosis despite the recent development of aggressive antitumor therapies. The cause of adrenal cancer remains elusive, but some molecular mechanisms could be responsible for its development. Target-specific therapies have been developed for a number of human malignancies and have resulted in therapeutic benefits in some cancer patients. However, these therapies are only effective in cases in which the corresponding targets are expressed in tumor tissues. Molecular analysis has had a significant impact on the understanding of the pathogenetic mechanism of ACC development and the evaluation of prognostic and predictive markers, among which alterations of the IGF system, the Wnt pathway, p53 and molecules involved in cancer cell invasion properties and angiogenesis seem to be very promising. These molecular markers may not just play a role in the biology of these tumors and have prognostic implications, but can also be used as potential targets for treatment. The aim of this review is to summarize the genetic and molecular events implied in the pathogenesis of ACC and to highlight challenges to the development of anticancer agents in recent patents.

Case report of a patient with initially inoperable well-differentiated midgut neuroendocrine tumor (WDNT)--PRRT and long-acting somatostatin analogs as the neoadjuvant therapy

A 43-year-old man was admitted to Surgery Department because of abdominal pain, vomiting, weight loss and flushes. Computed tomography (CT) examination revealed upper and middle abdomen tumor of about 110 × 110 mm. Histopathological analysis of the tissues obtained during the exploratory laparotomy confirmed WDNT (well-differentiated neuroendocrine tumor according to the WHO classification 2000). The patient received 5 doses of chemotherapy without any response. A positive result of 99mTc-[EDDA/Hynic] Octreotate scintigraphy (SRS) gave the possibility of PRRT (peptide receptor radionuclide therapy). The patient was treated with the total dose of 400 mCi of 90Y-DOTA-TATE. CT performed after the PRRT revealed regression of the tumor size to 72 × 94 mm. A decrease of CgA level and release of symptoms were also observed. Aiming at the removal of the considerable diminished tumor the patient was qualified for the second laparotomy. "Cytoreduction" surgery with partial excision of the tumor was performed. Additionally tumor-affected appendix was removed. The second focus of WDNT (according to the WHO classification 2000) with Ki67 < 1% was found in the appendix. Pathologists confirmed the above-mentioned lesions as independent (an extremely rare clinical situation). The following treatment with long-acting somatostatin analogs and 300 mCi of 90Y-DOTA-TATE resulted in further regression of the tumor size to 25 × 35 mm. Consecutive laparotomy is considered. If complete tumor removal might be achieved is an open question. The above case report shows the efficacy of combined therapy with the use of "hot" and "cold" somatostatin analogs not only in controlling the symptoms of the disease but also in obtaining tumor size regression making surgical intervention possible. Such a neoadjuvant therapy seems to be a promising tool in the management of patients with initially inoperable neuroendocrine tumors.

Management of Hyperthyroidism in Pregnancy: Results of a Survey among Members of the European Thyroid Association

BACKGROUND

An optimal management of maternal hyperthyroidism is important for positive pregnancy outcome, and to this end, the Endocrine Society published their guidelines in 2007. This survey aimed to investigate to what extent the clinical practice relating to the management of hyperthyroidism during pregnancy in Europe is uniform and consistent with the guidelines.

MATERIALS AND METHODS

We e-mailed an online questionnaire survey based on clinical case scenarios to 605 members of the European Thyroid Association. We analysed 190 responses from 28 European countries.

RESULTS

For a woman with newly diagnosed Graves' disease (GD) and wishing pregnancy, 78% of the responders would initiate antithyroid drugs (ATDs), while 22% would recommend definitive treatment with radioiodine or surgery. In case of a relapsed GD before pregnancy, 80% preferred definitive treatment. For a woman with newly diagnosed GD during pregnancy, 53% would treat with propylthiouracil, 12% with methimazole, and 34% with propylthiouracil initially and switch to methimazole after the first trimester. Responders used several combinations of tests to monitor the dose of ATDs, and the thyroid test results they targeted were inconsistent. For a lactating woman with GD, 68% would give ATDs without stopping lactation.

CONCLUSIONS

Variation in the clinical practices surrounding the management of hyperthyroid pregnant women in Europe still exists.

Expression of cyclooxygenase-2 (COX-2) in pituitary tumours

BACKGROUND

Microvessel density in angiogenesis is regarded as a prognostic factor of tumour invasiveness, independent of cell proliferation. In recent studies of pituitary tumours, correlation between the expression of cyclooxygenase-2 (COX-2) and micro-vascularization density and microvessel surface density has been established. We studied the expression of COX-2 in different types of pituitary adenomas to determine the usefulness of COX-2 expression as a prognostic factor of tumour progression or recurrence in patients with hypophyseal tumours.

MATERIAL/METHODS

We retrospectively studied a group of 60 patients of mean age 46.7±17.6 (range, 18 to 85) years who underwent pituitary tumour surgery. Expression of COX-2, as determined by immunohistochemistry, was analyzed in relation to histopathology features of tumour, clinical symptoms, MR imaging and post-operative recurrence/progression of disease.

RESULTS

COX-2 was expressed in adenomas of 87% of patients, with a median index value of 57.5% [IQR=60.5]. Highest COX-2 expression was observed in hormonally inactive adenomas and gonadotropinomas and lowest in prolactinomas. We found no differences in COX-2 expression with respect to patient age, gender, tumour size, degree of tumour invasiveness, or whether tumours were immunopositive or immunonegative for pituitary hormones, nor have we found any relation between COX-2 expression and recurrence or progression of tumour size.

CONCLUSIONS

COX-2 does not appear to be a predictive factor for recurrence or progression of tumour size. Nevertheless, due to the observed relatively high expression of COX-2 in pituitary adenomas, further studies with COX-2 inhibitors are justified in these tumours.

Factors connected with the female sex seem to play an important role in differentiated thyroid cancer

AIM

The aim of the study was to analyze whether female sex hormones and other factors connected with the female sex could increase the risk of differentiated thyroid cancer (DTC).

MATERIAL AND METHODS

Ninety-nine patients with a mean age±SD of 40.5±5.9 years with DTC and 51 healthy women with a mean age of 36.52±8.3 years were examined. Gynecological and obstetric histories were taken and serum estradiol and progesterone levels were analyzed in all women.

RESULTS

Patients with DTC had more frequent menstrual cycle disturbances, used hormone-containing medicines more frequently, were mulitiparous more frequently, had spontaneous miscarriages more frequently, and their duration of lactation was significantly shorter than in controls. The mean serum estradiol level±SD in women with DTC was significantly higher than in the controls, in the follicular phase 193.74±66.31 vs. 157.63±42.88 pmol/l and in the luteal phase 519±176.9 vs. 369±71.49 pmol/l. The mean serum progesterone level±SD was higher in the controls than in patients with DTC, in the follicular phase: 2.11±0.70 vs. 1.38±0.56 nmol/l and in the luteal phase 20.95±17.46 vs. 17.31±12.28 nmol/l.

CONCLUSIONS

The results of these studies imply that estrogens may at least modify the proliferation of thyroid cancer cells. The sex hormones probably intensify the actions of other carcinogens as well.

Goiter, cardiovascular and metabolic disorders in patients with acromegaly

OBJECTIVE

This study evaluated the relationship between selected acromegaly complications such as IGF-1 serum concentrations at diagnosis as well as of controlled and uncontrolled disease.

METHODS

A total of 113 acromegaly patients were enrolled to the study and the duration of active and uncontrolled disease was evaluated as a crucial cause of selected complications.

RESULTS

Goiter, diabetes, hypercholesterolemia, hypertriglycerydemia, hypertension and ischemic heart disease were diagnosed in 85(75.2 %), 23(20.3 %), 48(51.0 %), 15(13.3 %), 65(57.5 %) and 18(15.9%) patients, respectively. Prevalence of goiter and diabetes was significantly related to the duration of uncontrolled acromegaly (p<0.01) as well as to the prevalence of hypertension and ischaemic heart disease (p0.05). After three years, there was a significant risk of an acromegaly patient being diagnosed at least with one of the above mentioned diseases (p<0.05) and such risk became more significant after four years (p0.05) related to the prevalence of the already mentioned complications.

CONCLUSION

The treatment of acromegaly patients should be geared towards fulfilling all criteria for controlled disease, thereby alleviating potential complications and decreasing mortality.

Randomized clinical trial of bilateral subtotal thyroidectomy versus total thyroidectomy for Graves' disease with a 5-year follow-up11

Background

The extent of thyroid resection in Graves' disease remains controversial. The aim of this study was to evaluate long-term results of bilateral subtotal thyroidectomy (BST) compared with total thyroidectomy (TT) in patients with Graves' disease and mild active ophthalmopathy.

Methods

Participants were assigned randomly to BST or TT, and followed for 5 years after surgery. The primary endpoints of the study were the prevalence of recurrent hyperthyroidism and changes in Graves' ophthalmopathy. Secondary endpoints were postoperative transient and permanent paresis of the recurrent laryngeal nerve, and postoperative hypocalcaemia and hypoparathyroidism.

Results

Two hundred patients were included, of whom 191 (BST 95, TT 96) completed the 5-year follow-up. Recurrent hyperthyroidism occurred in nine patients after BST and in none after TT (P = 0·002). Progression of Graves' ophthalmopathy was observed in nine patients after BST compared with seven following TT (P = 0·586). Transient hypoparathyroidism occurred in 13 and 24 patients respectively (P = 0·047). Permanent hypoparathyroidism was diagnosed in no patient after BST and in one after TT (P = 0·318). No differences were noted in transient or permanent recurrent laryngeal nerve injury.

Conclusion

TT for Graves' disease prevented recurrent hyperthyroidism but did not prevent the progression of ophthalmopathy compared with BST. Registration number: NCT01408368 (http://www.clinicaltrials.gov).

Imaging of inflamed carotid artery atherosclerotic plaques with the use of 99mTc-HYNIC-IL-2 scintigraphy in end-stage renal disease patients

PURPOSE

Identification of vulnerable plaques remains crucial for better cardiovascular risk assessment. At least 20% of inflammatory cells within unstable (vulnerable) plaques comprise T lymphocytes, which contain receptors for interleukin-2 (IL-2); those receptors can be identified by scintigraphy with radiolabelled IL-2.The aim of this study was to identify the "inflamed" (vulnerable) plaques by scintigraphy using IL-2 labelled with (99m)Tc in the selected, high cardiovascular risk group of end-stage renal disease (ESRD) patients.

METHODS

A total of 28 patients (18 men, 10 women, aged 55.2 ± 9.6 years, 17 on peritoneal dialysis, 11 on haemodialysis) underwent common carotid artery (CCA) scintigraphy with the use of (99m)Tc-hydrazinonicotinamide (HYNIC)-IL-2. In all cases, ultrasound examination of the CCA was performed and levels of selected proinflammatory factors, atherogenic markers and calcium-phosphate balance parameters were measured. Finally, the target to non-target (T/nT) ratio of IL-2 uptake in atherosclerotic plaques with intima-media thickness (IMT), classic cardiovascular risk factors and concentrations of the measured factors were compared.

RESULTS

Increased (99m)Tc-HYNIC-IL-2 uptake in atherosclerotic plaques in 38/41 (91%) cases was detected. The median T/nT ratio of focal (99m)Tc-HYNIC-IL-2 uptake in atherosclerotic plaques was 2.35 (range 1.23-3.63). The mean IMT value on the side of plaques assessed by scintigraphy was 0.79 ± 0.18 mm (median 0.8, range 0.5-1.275). Correlations between T/nT ratio and homocysteine (R = 0.22, p = 0.037), apolipoprotein B (apoB) (R = 0.31, p = 0.008), apoB to apoA-I ratio (R = 0.29, p = 0.012) and triglyceride concentration (R = 0.26, p = 0.021) were detected. A lower T/nT ratio in patients with better parameters of nutritional status (haemoglobin, albumin, adiponectin) in comparison with patients with worse nutritional parameters (3.20 ± 0.5 vs 2.16 ± 0.68, p = 0.025) was revealed as well as a difference between values of T/nT ratio in groups of patients with values of apoB, soluble CD40 ligand and asymmetric dimethylarginine above and below median (3.18 ± 0.52 vs 2.16 ± 0.68, p = 0.031). No statistically significant association was found between T/nT ratio and mean value of either IMT or classic cardiovascular risk factors.

CONCLUSION

Scintigraphy with the use of (99m)Tc-HYNIC-IL-2 can be a tool for inflamed atherosclerotic (vulnerable) plaque visualization within CCA in ESRD patients. Quantitative results of carotid artery scintigraphy with (99m)Tc-HYNIC-IL-2 correlate with serum concentration of selected cardiovascular risk markers.

Dietary patterns as risk factors of differentiated thyroid carcinoma

Nutritional factors are known to be important in the development of different metabolic diseases. The history of nodular or diffuse goiter is closely related to risk of thyroid carcinoma. On account of the function of the thyroid gland, many studies focus on iodine intake. The aim of the study was to assess whether dietary patterns could be risk factors of differentiated thyroid carcinoma.

MATERIAL/METHODS

The case-control study was based on a questionnaire, which included information about dietary patterns and was carried out on 284 patients comprising 30 males (mean age 58.4±13.7 years), and 254 females (mean age 52.1±13.8 years), as well as 345 randomly selected controls: 58 males (mean age 60.2±12 years) and 287 females (mean age 53.4±14.3 years) randomly selected from the Population Register and adjusted by age and gender to the group of TC. The main groups of nutritional products, i.e. starchy foods, meat, dairy products, vegetables, fruits, and beverages, were analyzed.

RESULTS

Consumption of vegetables, fruits, saltwater fish and cottage cheese was significantly lower in patients with differentiated thyroid carcinoma than in controls, quite the contrary to starchy foods, especially white bread.

CONCLUSIONS

Dietary patterns appear to modify the risk of thyroid carcinoma. A diet rich in vegetables and fruit, as well as saltwater fish (a source of iodine) and low-fat meat, could be an important protective factor.

[Hematological toxicity of radioimmunotherpy with 90Y Ibritumomab]

Radioimmunotherapy with 90Y Ibritumomabu (Zevalin, BSP) is a new method of systemic radiotherapy applicable to B-cell lymphoma patients. It may be delivered as a short outpatient procedure, with few adverse effects other than hematological toxicity. In the paper, we present length and depth of cytopenias, together with the results of additional tests performed to reveal the possible pathomechanisms, based on 102 patients treated at the University Hospital in Krakow.

[Symptoms and early diagnostic possibilities of pancreatic endocrine cells hyperplasia (nesidioblastosis)]

Nesidioplastosis in adults is one of a rare causes of hyperinsulinemic hypoglycemia. Symptoms include chronic or recurrent hypoglycemias, often with neurological signs. Due to the looses of consciousness with coexisting seizures, in many cases patients are treated on epilepsy. Right diagnosis is usually late established, when the damages in the central nervous system (CNS) are irreversible. Early diagnosis of the disease and appropriate treatment might help to avoid serious disability in these patients. The aim of the study was to asses modern diagnostics of the nesidioblastosis with an emphasis on the biochemical and hormonal tests and imaging modalities. Patients enrolled to the study were aged between 18 and 72 years of age, and had chronic or recurrent hypoglycemia caused by hyperinsulinemia. In all patients fasting glucose and fasting insulinemia tests were performed, as well as the fasting blood test or in the 24-hour profile tests. Several techniques were used including ultrasound (US), abdominal computer tomography (CT), in two patients magnetic resonance imaging, scintigraphy of somatostatin receptors in seven patients, and in two patients scintigraphy with glucagone-like peptide-1 (GLP-1) analogue-labeled marker was done. In the performed tests low values of the blood glucose were found, whereas insulin levels, however not adequate to the blood glucose, were nearly always within the normal range. In the standard imaging only in one patient tumor lesion in the pancreatic tail was revealed, though not confirmed in the intraoperative histology. In the scintigraphy examination with the somatostatin analogue in one patient slightly increased collection of the marker in whole pancreas was reported and in the other patient focal collection in the pancreatic tail was observed. Scintigraphy with GLP-1 analogue revealed focal collection of the marker in one case. Five patients were underwent surgical treatment. In the histopathology in all operated patients hyperplasia of the endocrine pancreatic cells with positive immuno. histochemic reaction on the insulin was found. In the three cases despite hyperplasia of pancreatic islets, small sizes insulinomas were detected as well. 1. The diagnosis of nesidioblastosis should be taken into consideration in all patients with unclear-cause hypoglycemias, in whom simultaneously insulin blood level is inadequate to the level of glucose. 2. Widely available imaging examinations: US, CT, MRI are useless in the diagnosis of nesidioblastosis. 3. Among the imaging methods in preoperative diagnostics of hypoglycemia with concomitant hyperinsulinemia somatostatin receptor scintigraphy seems to have specific, though limited role - it is valuable only in the severe, diffused lesions. 4. Recurrent hypoglycemias after 70% excision of the pancreas may indicate the possibility of coexistence of pancreatic islets hyperplasia and insulin secreting insulinoma.

Reference values for thyroid volume established by ultrasound in Polish schoolchildren

INTRODUCTION

A frequency in excess of 5% of goitre in children is an approved WHO marker of iodine deficiency. As thyroid ultrasound remains the main method of thyroid volume (TV) assessment, the choice of adequate normative values is important for the proper interpretation of epidemiologic data. There is disagreement as to whether local or international normative values should be used. The aim of this study was to establish Polish local TV normative values in children aged 6-12 years.

MATERIAL AND METHODS

The study was carried out in a group of 642 children aged 6-12 years (312 girls and 330 boys) living in the Polish seaside area with a proven history of best iodine supply. Inclusion criteria were: iodine concentration in casual morning urine samples above 100 μg/L, no goitre on palpation, no pathological findings on thyroid US, no history of thyroid disorders, no treatment affecting thyroid function, and written informed consent from the child's parents. TV was measured ultrasonographically with a 7.5 MHz linear transducer. Urinary iodine concentration (UIC) was measured in urine spot samples using the Sandell-Kolthoff method.

RESULTS

Median UIC ranged according to age from 126.6 to 155.1 μg/L in girls, and from 132.23 to 157.62 μg/L in boys. TVs at P97 were: 3.96, 4.23, 4.33, 5.44, 6.07, 9.5, and 10.9 for girls and 3.99, 4.2, 4.79, 6.61, 7.38, 7.89, and 9.35 for boys. They were lower than the 1997 WHO normative values but higher than the 2004 reference currently adopted by the WHO.

CONCLUSIONS

The obtained results may be adopted as normative TV values for Polish children.

Treatment and screening of hypothyroidism in pregnancy: results of a European survey

BACKGROUND

Maternal hypothyroidism in pregnancy is associated with several adverse outcomes. The Endocrine Society Guidelines for the management of thyroid diseases in pregnancy were published in 2007; however, impact of the guidelines in routine clinical practice is unknown. Therefore, we have carried out a survey of members of the European Thyroid Association (ETA) to study current practices relating to the management of hypothyroidism in pregnancy.

SUBJECTS AND METHODS

In December 2010, we emailed an electronic questionnaire survey based on clinical case scenarios to 605 members of the ETA. Responses from 190 clinician members (from 28 European countries) were analyzed.

RESULTS

For a pregnant woman with newly diagnosed overt hypothyroidism, most responders initiated a full dose of l-thyroxine (l-T(4)). For a woman with hypothyroidism planning pregnancy, 50% recommended increasing the dose of l-T(4) as soon as pregnancy is confirmed, whilst 43% favored testing thyroid function before adjusting the dose. Responders used diverse combinations of tests to monitor the dose of l-T(4). The target of thyroid function tests that responders aimed to achieve with l-T(4) was also inconsistent. Forty-two percent responders or their institutions screened all pregnant women for thyroid dysfunction, 43% performed targeted screening of only the high-risk group, whilst 17% did not carry out systemic screening. Timing of the screening, tests used, and criteria for starting treatment and monitoring were variable.

CONCLUSIONS

There is wide variation in the clinical practice relating to the treatment and screening of hypothyroidism during pregnancy in Europe.

Positive family history of thyroid disease as a risk factor for differentiated thyroid carcinoma

INTRODUCTION

Apart from the environmental risk factors for differentiated thyroid carcinoma (DTC), such as iodine deficiency and ionising radiation, it seems that there are also other, biological risk factors, for example, familial predisposition to thyroid disease.

OBJECTIVES

The aim of the study was to assess the occurrence of thyroid disease in the families of patients with DTC.

PATIENTS AND METHODS

A case-control study was conducted in a group of 232 patients with DTC and in 342 age- and sex-matched healthy subjects. Eighty patients were diagnosed with follicular thyroid carcinoma, 127 with papillary thyroid carcinoma, and 25 with oxyphilic thyroid carcinoma. The questionnaire included questions on the presence of thyroid diseases in first-degree relatives. The relative risk of DTC and the effect of factors associated with thyroid diseases in the family were assessed by the logistic regression model.

RESULTS

Thyroid disease was more common in the families of DTC patients than in the control group: 18.5% of the patients and 9.6% of the control group had a parent with thyroid disease (OR = 2.12, 95% CI: 1.26-3.55); 16.8% of the patients and 7.7% of the control group had a sibling with thyroid disease (OR = 2.27, 95% CI: 1.31-3.95).

CONCLUSIONS

Familial thyroid disease may be a risk factor for DTC. A positive family history of thyroid disease is associated to a larger extent with the development of papillary thyroid carcinoma than with that of follicular thyroid carcinoma.

Factors connected with the female sex seem to play an important role in differentiated thyroid cancer

AIM

The aim of the study was to analyze whether female sex hormones and other factors connected with the female sex could increase the risk of differentiated thyroid cancer (DTC).

MATERIAL AND METHODS

Ninety-nine patients with a mean age ± SD of 40.5 ± 5.9 years with DTC and 51 healthy women with a mean age of 36.52 ± 8.3 years were examined. Gynecological and obstetric histories were taken and serum estradiol and progesterone levels were analyzed in all women.

RESULTS

Patients with DTC had more frequent menstrual cycle disturbances, used hormone-containing medicines more frequently, were mulitiparous more frequently, had spontaneous miscarriages more frequently, and their duration of lactation was significantly shorter than in controls. The mean serum estradiol level ± SD in women with DTC was significantly higher than that in the controls, in the follicular phase 193.74 ± 66.31 vs. 157.63 ± 42.88 pmol/L and in the luteal phase 519 ± 176.9 vs. 369 ± 71.49 pmol/L. The mean serum progesterone level ± SD was higher in the controls than in DTC patients in the follicular phase: 2.11 ± 0.70 vs. 1.38 ± 0.56 nmol/L; in the luteal phase: 20.95 ± 17.46 vs. 17.31 ± 12.28 nmol/L.

CONCLUSIONS

The results of these studies imply that estrogens may at least modify the proliferation of thyroid cancer cells. The sex hormones probably intensify the actions of other carcinogens as well.

Prevention of type 2 diabetes by lifestyle intervention in primary health care setting in Poland: Diabetes in Europe Prevention using Lifestyle, physical Activity and Nutritional intervention (DE-PLAN) project

Aim

To find out whether diabetes prevention via a lifestyle intervention programme is feasible in a primary healthcare setting in Poland.

Methods

The intervention (Diabetes in Europe: Prevention using Lifestyle, physical Activity and Nutritional intervention; DE-PLAN project) was completed by 175 middle-aged, slightly obese participants in nine primary healthcare centres in Krakow, Poland. The inclusion criterion was diabetes risk (Finnish Diabetes Risk score (FRS) >14). The nurse-delivered intervention consisted of 10 group sessions on lifestyle changes, six motivational telephone sessions, two motivational letters and the opportunity to participate in once or twice weekly physical activity sessions.

Results

At 12 months there were mean reductions in weight, 85.7 to 83.7 kg; body mass index, 31.8 to 31.1 kg/m2 (p<0.05); waist circumference, 98.8 to 95.5 cm (p<0.05); total cholesterol 5.6 to 5.3 mmol/L (p<0.05), systolic and diastolic blood pressure 133 to 130 and 83 to 81 mmHg respectively (p<0.05); FRS 18–16 (p<0.05) and 25% of participants lost ≥5% of initial body weight. No changes were observed in fasting or 2-h post-oral glucose tolerance test plasma glucose, triglycerides, or high-density lipoproteins. Significant improvements were found in lifestyle risk factors like diet and physical activity.

Conclusions

Prevention of type 2 diabetes through lifestyle intervention is feasible in primary healthcare settings in Poland.

Thyroid disorders-assessments of trace elements, clinical, and laboratory parameters

The trace elements studied in this work (Se, Cu, Zn) are the essential constituents or cofactors required to activate numerous enzymes and proteins, playing crucial role in various physiological processes. The disturbed levels of abovementioned elements may adversely affect the endocrine system, resulting in various thyroid disorders among other upsets. The aim of this study was to investigate possible associations between them and parameters of redox balance, thyroid function indices as well as clinical records (duration of disease and therapy, lag time between thyroid surgery and this study examination, LT4 dosage) in patients with different thyroid disorders, including malignant diseases of the gland. In the group of patients with papillary carcinoma, we found a statistically significant higher Cu concentration compared with controls and patients with Hashimoto disease. In the same groups, the parameter of Zn/Cu ratio demonstrated reciprocally arranged statistically significant differences. For the group of papillary cancer patients, there was a negative correlation between lag time since thyroid operation and GPX3 activity. Our data support hypothesis of indirect involvement of Zn and Cu in thyroid regulation. For selenium, lack of simple correlation between its serum level and thyroid indices implies the need for further research on other selenium status parameters more adequately depicting changes in endocrine system.

Efficacy and complications of neurosurgical treatment of acromegaly

The aim of the study was to evaluate the frequency of occurrence of pituitary failure following neurosurgery and the efficacy of transsphenoidal tumour resection in acromegalic patients. We retrospectively evaluated 85 patients (60 female and 25 male), of mean age 43.9 ± 13.2 years, treated by transsphenoidal neurosurgery. Macroadenoma and microadenoma of pituitary were found in 66 (77.6%) and 19 (22.4%) of these patients, respectively. Criteria of cure following neurosurgery were: basal GH<2.5 μg/l, GH at 120 min in OGTT<1.0 μg/l and serum concentration of IGF-1 within normal ranges for age and sex. After surgery 32 patients (37.6%) were cured and 53 patients (62.4%) required somatostatin analogue treatment. In patients cured by surgery, lower levels of basal GH (P<0.05), IGF-1 (P<0.001), GH at 120 min in OGTT and smaller size of pituitary tumour (P<0.05) were found at diagnosis, as compared to patients in whom surgery was unsuccessful. Significant correlation between basal serum level of GH at diagnosis and size of pituitary tumour was found (P<0.001). Invasive tumours were found in 45 of 53 (84.9%) patients not cured and in only 8 of 32 (25.0%) patients cured (P<0.001). Impaired function of pituitary anterior lobe after surgery was observed in 30% and 4% of patients with macro- and microadenoma, respectively (P<0.05). The efficacy of neurosurgery is affected by concentration of basal serum GH and IGF-1, GH at 120 min in OGTT, tumour size and invasiveness. Hypopituitarism after surgery is more frequent in patients with macroadenoma. Pituitary insufficiency, as a consequence of surgery, was found in 21% of patients with normal pituitary function prior to operation.

Peptide receptor radionuclide therapy as a potential tool for neoadjuvant therapy in patients with inoperable neuroendocrine tumours (NETs)

Purpose

Neuroendocrine tumours (NET) are a heterogeneous group of neoplasms of diffuse neuroendocrine cells. Surgery is the main aim in the treatment of NETs, which becomes impossible in the case of large tumours or infiltration into other tissues and/or important blood vessels. Neoadjuvant therapy might be helpful in decreasing NET size also, leading us to the point where a tumour, previously considered inoperable, becomes operable. The aim of the study was to assess the usage of peptide receptor radionuclide therapy (PRRT) as a neoadjuvant treatment, enabling surgical intervention in primary inoperable NET.

Methods

Among 47 patients treated with PRRT, 6 patients were chosen with large, inoperable tumours, for whom enabling of complete surgical excision of the lesions might offer the prospect for a cure. Response to the therapy was assessed according to Response Evaluation Criteria In Solid Tumors (RECIST).

Results

The mean tumour size decreased from 6.9 (min. 3.1 cm, max. 9.6 cm) before therapy to 5.4 cm (min. 3.1 cm, max. 9.5 cm) after the treatment. According to RECIST, stabilization of the disease was observed in four and partial responses in two patients. In two patients, reduction of the tumour size enabled surgical intervention.

Conclusion

(1) PRRT might be considered a neoadjuvant therapy in primary inoperable NETs. (2) According to RECIST, stabilization of the disease was observed in the majority of patients. (3) We suggest that not only tumour diameter changes, but also tumour volume and contrast enhancement changes in computed tomography should be taken into consideration in assessment of the response to the therapy. (4) Somatostatin receptor scintigraphy is an important tool for qualification of the radioisotope therapy and also for the assessment of the response to PRRT.

Clinical results of radionuclide therapy of neuroendocrine tumours with 90Y-DOTATATE and tandem 90Y/177Lu-DOTATATE: which is a better therapy option?

Purpose

Peptide receptor radionuclide therapy (PRRT) using radiolabelled somatostatin analogues is a treatment option for patients with disseminated neuroendocrine tumours (NET). A combination treatment using the high-energy ⁹⁰Y beta emitter for larger lesions and the lower energy ¹⁷⁷Lu for smaller lesions has been postulated in the literature.The aim of the study was to evaluate combined ⁹⁰Y/¹⁷⁷Lu-DOTATATE therapy in comparison to ⁹⁰Y-DOTATATE alone.

Methods

Fifty patients with disseminated NET were included in the study prospectively and divided into two groups: group A (n = 25) was treated with ⁹⁰Y-DOTATATE, whereas group B (n = 25) received the 1:1 ⁹⁰Y/¹⁷⁷Lu-DOTATATE. The administered activity was based on 3.7 GBq/m² body surface area in three to five cycles, with amino acid infusion for nephroprotection.

Results

The median overall survival time in group A was 26.2 months while in group B median survival was not reached. Overall survival was significantly higher in group B (p = 0.027). Median event-free survival time in group A was 21.4 months and in group B 29.4 months (p > 0.1). At the 12-month follow-up, comparison of group A vs group B showed stable disease (SD) in 13 vs 16 patients, disease regression (RD) in 5 vs 3 patients and disease progression (PD) in 3 vs 4 patients; 4 and 2 patients died, respectively. The 24-month follow-up results were SD in nine vs ten patients, RD in one patient vs none and PD in four patients in both groups; three and four patients died, respectively. Side effects were rare and mild.

Conclusion

The results indicate that therapy with tandem radioisotopes (⁹⁰Y/¹⁷⁷Lu-DOTATATE) provides longer overall survival than with a single radioisotope (⁹⁰Y-DOTATATE) and the safety of both methods is comparable.

The somatotropic axis in postmenopausal women during six month of transdermal continuous 17beta-estradiol administration combined with oral medroxyprogesterone

AIM

The evaluation of the influence of continuous transdermal estradiol supplementation combined with oral medroxyprogesterone on the somatotropic axis in postmenopausal women.

MATERIAL AND METHODS

25 women completed the study Group A--13 women received transdermal 17beta-estradiol (Oesclim 50 - Fournier-Solvay) combined with oral 5 mg daily medroxyprogesterone (Gestomikron - Adamed). Group B--12 women without treatment. Basic plasma FSH, estradiol, glucose, insulin, SHBG, hGH, total and free IGF-I, IGFBP-1 as well as IGFBP-3 were measured initially and at the 12th and 24th week of the study.

RESULTS

The mean plasma FSH level was reduced and mean plasma estradiol level was increased in group A during estradiol supplementation. Mean plasma level of free IGF-I and free to total IGF-I ratio were increased in group A during 24 weeks of hormone therapy. In the control group (group B) there was the significant increase in mean plasma IGFBP-3 level. Other parameters showed no significant changes in the control group.

CONCLUSION

The administration of transdermal 17beta-estradiol combined with oral medroxyprogesterone increases the IGF-I bioavailability. However this influence do not exceed the physiologial level of IGF-I bioavailability.

[Influence of estradiol administration mode on plasma insulin-like growth factor-I (IGF-I) and its binding proteins 1 and 3 concentration in postmenopausal women treated with norethisterone acetate]

AIM

The aim of the present work was to assess the influence of estradiol administration mode on the plasma IGF-I, IGFBP-1, IGFBP-3 levels in postmenopausal women treated with norethisterone acetate.

MATERIAL AND METHODS

39 women were enrolled into the study Group A--14 women received transdermal 17beta-estradiol (Oesclim 50--Fournier-Solvay) combined with oral norethisterone 2.5 mg daily (Primolut-Nor--Schering), Group B--10 women on oral 2 mg 17beta-estradiol combined with oral 1 mg daily norethisterone (Kliogest--Novo-Nordisk). Control group (group C) consisted of 15 postmenopausal women who received no treatment. Basic plasma FSH, estradiol and total IGF-I, IGFBP-1 as well as IGFBP-3 levels were measured initially and at the 52nd week of the study.

RESULTS

The mean plasma FSH level was reduced and mean plasma estradiol level was increased in groups A and B during hormone therapy. Mean plasma levels of total IGF-I, IGFBP-1, IGFBP-3 as well as IGFBP-3/IGF-I ratio did not changed significantly during 52 weeks of observation in groups A, B and C. The comparison of plasma IGF-I, IGFBP-1, IGFBP-3 between groups at the initial visit and after 52 weeks showed the lowest concentration f IGBP-3 in group B. Other parameters showed no differences among the three groups.

CONCLUSION

Mode of administration of estradiol did not influenced the plasma levels of IGF-I, IGFBP-1, IGFBP-3 in postmenopausal women treated with norethisterone acetate.

Octreotide lar affects the volume of pituitary adenoma in acromegalic patients

INTRODUCTION

We studied changes of pituitary adenoma volumes in patients treated with octreotide LAR (SSLAR) over 12 months prior to surgery.

MATERIALS AND METHODS

26 patients (22 female and 4 male, mean age 57.5±15.0 years) were treated with SSLAR: 5 patients with microadenoma - during 6 months, and 21 patients with macroadenoma - during 12 months before surgery. Concentration of hGH and IGF-1 was evaluated at 0, 3, 6 and 12 months, while MRI images were taken at 0, 6 and 12 months prior to surgery. The volume of pituitary adenoma, estimated as that of an ellipsoid, was based on MRI image projections. Basic statistics, Shapiro-Wilk and Wilcoxon tests were applied.

RESULTS

Median values of hGH and IGF-1 concentrations prior to treatment were 19.0 ng/ml (IQR=40.7) and 766.4 ng/ml (IQR=787.7), respectively. After 6 and 12 months the median value of hGH concentration decreased to 6.3 ng/ml (IQR=9.0) and 3.45 ng/ml (IQR=3.7), respectively, while the median values of IGF-1 became 535.0 ng/ml (IQR=652.8) and 287.0 (IQR=275.7), respectively. All differences were statistically significant (p<0.05) as compared to basal value. The median volumes of adenomas differed significantly and were estimated at: 1.1 cm (3) (IQR=2.5) prior to treatment, 0.5 cm (3) (IQR=1.5) after 6 months, and 0.35 cm (3) (IQR=2.4) after 12 months of SSLAR administration.

CONCLUSION

Treatment of acromegalic patients with somatostatin analogues not only decreases the concentration of hGH and IGF-1, but also appears to decrease the size of the tumour in about 50% of patients treated, leading to general enhancement of the outcome of surgery.

Intake of iodine-containing multivitamin preparations by pregnant women from the Krakow region of Poland

BACKGROUND

The aim of this study was to evaluate the number of women who take multivitamin formulations containing iodine.

MATERIAL AND METHODS

A 34-question questionnaire was given to 500 women during their puerperal stay in two obstetrics/gynaecology wards in Krakow.

RESULTS

295 pregnant women (59%) took iodine-containing formulations. 205 pregnant women (41%) took multivitamin preparations without iodine. 49.7% of the women (91 out of 183) who inhabited rural areas and small towns were not supplemented with iodine during pregnancy. Women in Krakow took iodine-containing multivitamin formulations in 61.2% of cases. Women with primary and secondary education did not use iodine supplementation in 48.3% and 50.3% of cases respectively. Women with a university education did not use supplementation in 38.6% of cases. The prevalence of women using iodine-containing multivitamin preparation was similar in each age group.

CONCLUSIONS

The promotion of iodine supplementation to pregnant women should be augmented at each level of contact with medical staff. Medical staff should be reminded about such promotion at each level of medical care and training (general practitioner, obstetrics/gynaecology specialist, endocrinologist, postgraduate training).

[The risk assessment of lungs' apices injury in patients after radioactive iodine therapy due to hyperthyroidism]

In the light of recent research data hypothesis on radioactive iodine therapy leading to inflammatory reaction in lungs' apices has lately gained wider acceptance among pulmonologists. The study published of late showed that in one female patient previously treated with radioiodine due to toxic multinodular goiter 99mTc-Tectreotide uptake was found in the lung apex. The aim of study was evaluation of the risk assessment of inflammatory reaction in lungs' apices among patients treated with radioactive iodine due to hyperthyroidism. The study was carried out in 15 female patients (mean age 75 years +/-10 years) with large toxic multinodular goiter and fine needle aspiration biopsy negative for malignancy and who did not qualify for thyreoidectomy. Mean radioactive iodine therapeutic dose used in the study was 940 MBq. Chest SPECT scan (99mTc-Tectreotide) was performed one year after radioiodine therapy. Trace uptake in lung apex has been noted only in one patient. In 14 out of 15 patients in the study tectreotide uptake has not been found in any lungs' apices. All of 15 patients became euthyroid six months after radioactive iodine therapy and had their thyroid gland shrinked. No significant correlation between inflammatory reaction in lung apices and radioiodine therapy in patients with hyperthyroidism and large multinodular goiter was found in conducted study.

Graves' ophthalmopathy in patients treated with radioiodine 131-I

BACKGROUND

Radioiodine treatment of hyperthyroidism in Graves' disease patients may cause or aggravate the course of ophthalmopathy (GO). We evaluated the activity and severity of ophthalmopathy in patients who acquired GO following radioiodine therapy.

MATERIAL AND METHODS

Between 2003 and 2005, 763 Graves' disease patients (50.9% of the total number of 1,500 patients referred to our Department) were treated with radioiodine 131-I. This treatment was only offered to patients with NOSPECS score < 3 and CAS < 3. Following their radioiodine treatment, in 39 patients (5.1% of all Graves' disease patients), mean age 53.9 ± 11.6 years, onset of GO was observed within 12 months of post-treatment follow-up.

RESULTS

In 39 patients who developed GO after 131-I treatment, median values of hTRAb and NOSPECS score were 15.4 U/L (IQR = 22.9) and 5.0 points (max = 8.0; min = 2.0), respectively, at the time of their GO onset. Patients were qualified for methylprednisolone pulse therapy (8.0 g) and subsequent radiotherapy (20 Gy). Median concentration of hTRAb and NOSPECS score at one, six and 12 months post-GO therapy were: 10.0 U/L (IQR = 21.6) and 4.0 (max = 6.0; min = 1.0); 7.5 U/L (IQR = 1.1) and 3.0 (max = 10.0; min = 0.0); 2.8 U/L (IQR = 8.3) and 3.0 (max = 6.0; min = 0.0), respectively. A positive association between hTRAb and NOSPECS score was observed over the control period. IL-6 and IL-2 concentration prior to and one month after treatment remained elevated.

CONCLUSIONS

Since 5% of our Graves' disease patients developed severe GO following radioiodine treatment, an association between radioiodine therapy and severe ophthalmopathy cannot be excluded. IL-6 and IL-2 concentrations remained elevated after glucocorticoid therapy.

[The impact of polychlorinated biphenyls on placental and ovarian steroidogenesis]

The structure and turnover of polichlorinated biphenyls (PCB) in environment was presented. The PCB absorption and metabolism in organisms as well as the PCB induced disruption of placental and ovarian steroidogenesis were discussed.

[Management of thyroid diseases during pregnancy]

The management of thyroid disorders during pregnancy is one of the most frequently disputed problems in modern endocrinology. It is widely known that thyroid dysfunction may result in subfertility, and, if inadequately treated during pregnancy, may cause obstetrical complications and influence fetal development. The 2007 Endocrine Society Practice Guideline endorsed with the participation of the Latino America Thyroid Association, the American Thyroid Association, the Asia and Oceania Thyroid Association and the European Thyroid Association, greatly contributed towards uniformity of the management of thyroid disorders during pregnancy and postpartum. Despite the tremendous progress in knowledge on the mutual influence of pregnancy and thyroid in health and disease, there are still important areas of uncertainty. There have been at least a few important studies published in the last 3 years, which influenced the thyroidal care of the expecting mother. It should also be remembered that guidelines may not always be universally applied in all populations with different ethnical, socio-economical, nutritional (including iodine intake) background or exposed to different iodine prophylaxis models. The Task Force for development of guidelines for thyroid dysfunction management in pregnant women was established in 2008. The expert group has recognized the following tasks: development of the coherent model of the management of thyroid dysfunction in pregnant women, identification of the group of women at risk of thyroid dysfunction, who may require endocrine care in the preconception period, during pregnancy and postpartum - that is in other words, the development of Polish recommendations for targeted thyroid disorder case finding during pregnancy, and the development of Polish trimester-specific reference values of thyroid hormones. Comprehensive Polish guidelines developed by the Task Force are to systematize the management of the thyroid disorders in pregnant women in Poland.

[Assessement of the usefulness of whole body scintigraphy after administration of 6 MBq of 131I in the diagnostic of breast cancer]

INTRODUCTION

Sodium-iodine symporter (NIS) belongs to a large family of natrium dependent ion transporters found in normal thyroid cells located on the basilar membrane of tyreocytes. Under physiologic conditions, the NIS is also present in other tissues: salivary glands, gastric mucosa, mammary glands during lactation, and vascular plexus of the fourth ventricle. NIS expression has also been found in many tumors, including breast cancer.

AIM

The aim of this study was to evaluate the usefulness of whole body scintigraphy after administration of relatively low activity of 131I (6 MBq)in the diagnostics of breast cancer.

MATERIAL AND METHODS

The study included nine women with breast cancer, aged 38-73 years (mean 55.6 +/- 11.7 years) and a control group of 14 women aged 29-84 years (mean 48.8 +/- 16.7 years). The uptake of radioiodine in whole body scintigraphy 24 hours after administration of 131I radioiodine (6 MBq) was compared between the control group and breast cancer patients. No pharmaceuticals reducing thyroid iodine uptake or increasing NIS expression were used.

RESULTS

Whole body scans using 6 MBq 131I activity revealed no focal radioiodine uptake outside the thyroid tissue in patients with breast cancer as well as volunteers from the control group.

CONCLUSIONS

Whole body scintigraphy using 131I, dosed at 6 MBq, with no additional treatment increasing extrathyroidal uptake of radioiodine, appears to be ineffective in the imaging of breast cancer.

Efficacy and safety of 90Y-DOTATATE therapy in neuroendocrine tumours

BACKGROUND

The aim of this study was to assess the efficacy and toxicity of peptide receptor radionuclide therapy (PRRT) with the use of the high affinity somatostatin receptor subtype 2 analogue, (90)Y labelled Tyr3-octreotate, ((90)Y-DOTATATE) in neuroendocrine tumours (NETs).

MATERIAL AND METHODS

46 patients with disseminated or non-operable NET were enrolled in this study. The (90)Y-DOTATATE therapeutic activity was calculated per total body surface area up to a total of 7.4 GBq/m(2) administered in three to five cycles, repeated every four to nine weeks. Before and after the therapy, blood tests for haematology, kidney and liver function, and chromogranin A were performed.

RESULTS

Out of 46 (90)Y-DOTATATE treated patients, one died before completing the therapy and 16 died after completing the therapy, among them one due to myocardial infarction. After 12 month follow-up, stabilisation of disease was observed in 47%, partial remission in 31%, and progression in 9% of the 45 patients who completed the therapy. Five patients died before completion of 12 months of follow-up. One of the patients died due to myocardial infarction. In one case, the information after 12 months is incomplete. The progression free survival was 37.4 months. During 12 months follow-up, transient decrease of PLT, WBC and haemoglobin values was observed. A transient increase of creatinine level (within normal ranges) and decrease of GFR values were found.

CONCLUSIONS

NETs (90)Y-DOTATATE therapy results in symptomatic relief and tumour mass reduction. The mild critical organ toxicity does not limit the PRRT of NETs.

Age, place of living and education influences the pregnancy universal thyroid function screening program attendance - questionnaire study

BACKGROUND

The aim of this study was to assess attendance at the universal screening programme for thyroid function in pregnancy and attempt to evaluate the influence of age, number of past pregnancies, level of education, and place of residence on the attendance. The study was performed by means of a questionnaire.

MATERIAL AND METHODS

Our study was performed on the basis of an anonymous questionnaire handed out to 543 women aged 16-45 years, on the third day of their puerperal stay in one of five obstetric wards in southern Poland. The questionnaire contained questions about participation in plasma level measurements of TSH, fT4, total T4, thyroid antibodies or thyroid ultrasound scanning at least once in pregnancy.

RESULTS

The rate of attendance at any examination of thyroid function among pregnant women was 26.7%. The highest attendance rate (32.7%) was found among women living in provincial capitals or with higher education (41.3%), whereas the lowest was among women who had completed only primary school (11%) and those living in county towns (15%). The number of previous pregnancies did not influence the thyroid screening attendance. Women over 21 years of age participated in this screening programme more frequently (27.1-30%).

CONCLUSION

Less than one third of pregnant women participated in the thyroid function screening. Place of living, education level, and age were the main factors influencing the attendance rate.

The predictive value of the IGF-1 level in acromegaly patients treated by surgery and a somatostatin analogue

BACKGROUND

We evaluated the predictive value of IGF-1 against hGH in the treatment outcome.

MATERIAL AND METHODS

A prospective study was undertaken of 47 patients (mean age 41.1 ± 12.9 years; 44 with macroadenoma and 3 with microadenoma), requiring treatment with octreotide LAR (SSLAR) following incomplete surgery. Concentrations of hGH and IGF-1 were measured three months after surgery and three, six, nine, 12, 18, and 24 months after introducing SSLAR.

RESULTS

Following surgery, respective median values of hGH and IGF-1 concentrations were 5.55 ng/mL (IQR = 7.1) and 512.7 ng/mL (IQR = 379.5). After six, 12, and 24 months of SSLAR treatment, median values of hGH decreased significantly: to 2.95 ng/mL (IQR = 5.5, p < 0.05), 2.95 ng/mL (IQR = 4.4, p < 0.05) and 2.00 ng/mL (IQR = 3.6, p < 0.001), respectively. After six, 12, and 24 months of SSLAR treatment, the respective median IGF-1 concentrations significantly decreased to 384.5 ng/mL (IQR = 312.2, p < 0.01), 323.0 ng/mL (IQR = 230.3, p < 0.001) and 334.0 ng/mL (IQR = 328.9, p < 0.01). The differences between median hGH and IGF-1 concentrations at 12 and 24 months were not significant. A statistically significant correlation was found between IGF-1 concentration prior to and after surgery (R = 0.61, p < 0.05) and prior to SSLAR treatment and IGF-1 concentration 24 months later (R = 0.49, p < 0.05). No such correlation was observed for hGH.

CONCLUSIONS

The level of IGF-1 prior to surgery and prior to SSLAR treatment is a better predictor of the treatment outcome than hGH. Octreotide LAR was most effective over the first 12 months of treatment. No further significant decrease of hGH or IGF-1 levels was observed past this period.

Radioiodine ablation of thyroid remnants in patients with differentiated thyroid carcinoma (DTC) following administration of rhTSH - a comparison with L-thyroxine withdrawal

INTRODUCTION

A group of differentiated thyroid carcinoma (DTC) patients receiving post thyroidectomy rhTSH-aided radioiodine treatment (group I) was compared with patients treated with ¹³¹I following endogenous stimulation of TSH (group II) after L-thyroxine withdrawal.

MATERIAL AND METHODS

Group I consisted of 66 patients of mean age 51.7 ± 16.2 years (58 females and 8 males). Group II included 76 patients of mean age 54.8 ± 14.7 years (67 females and 9 males). All patients underwent total thyroidectomy and central lymph node dissection and additionally lateral lymph node excision, if required. Prior to radioiodine treatment thyroid volume (VT) and 24-hour ¹³¹I uptake were evaluated. TSH and Tg concentrations were measured prior to and after endogenous and exogenous stimulation of TSH. Whole-body post-therapeutic scintigraphy was evaluated. Basic statistics, W Shapiro-Wilk, Wilcoxon, and U Mann-Whitney tests were applied.

RESULTS

Median values of VT and of 24-hr ¹³¹I uptake in groups I and II were not significantly different. The differences between median values of serum TSH concentration after stimulation in groups I and II were statistically significant (p < 0.05), respective medians being 100.0 μU/mL (IQR = 107.3) and 78.8 μU/mL (IQR = 47.7). Median values of serum Tg concentrations in groups I and II following TSH stimulation prior to radioiodine treatment were 2.6 ng/ml (IQR = 8.4) and 4.9 ng/mL (IQR = 12.6), respectively, the difference not being statistically significant. Following rhTSH treatment no adverse effects were observed compared to LT4 withdrawal.

CONCLUSIONS

rhTSH may be safely used for ¹³¹I thyroid remnant ablation in low-risk DTC patients.

A case of acromegaly and disseminated follicular thyroid carcinoma

INTRODUCTION

A particularly challenging case of concurrent acromegaly and follicular thyroid carcinoma in a patient of the Clinic of Endocrinology, UJCM in Krakow is discussed.

CASE DESCRIPTION

A 59-year-old male with post total thyroidectomy performed in 2005 and histopathologically confirmed metastases of the follicular thyroid carcinoma to the lungs was admitted to the Clinic in April 2006 for complementary ¹³¹I treatment. Acromegaly was treated in 1996 by trans-sphenoidal surgery. In December 2005 a relapse of pituitary adenoma was shown by MRI, which correlated with increased levels of hGH and IGF-1. Biochemical control of acromegaly was achieved with Sandostatin LAR. Pre-therapeutic whole-body scintigraphy (WBS) revealed numerous conjoined hot spots of ¹³¹I accumulation in both lungs and in thyroid remnants. In May and November 2006 the patient received ¹³¹I treatment. Post-therapeutic WBS in November 2006 revealed complete ablation of the thyroid remnants. Laboratory tests confirmed lowering of thyroglobulin concentration. In the years 2007, 2008, and 2009 the patient was qualified for therapy with ¹³¹I aided by rhTSH, achieving further reduction of Tg levels. Post-therapeutic WBS performed in 2009 revealed weak bilateral tracer uptake in the lung parenchyma. In 2010, chest CT revealed fibrosis in left lung segments, no infiltrative changes, and no lymph node enlargement. Patient follow-up continues at our Department.

CONCLUSIONS

Disseminated thyroid cancer in a patient with pituitary insufficiency may be successfully treated by rhTSH-supported ¹³¹I treatment.

Neuroendocrine tumours of rare location

Neuroendocrine tumours (NETs) arising from dispersed endocrine system may originate from almost every location, although they are most commonly found in the gastrointestinal tract and respiratory system. NETs are considered as particularly rare if they constitute less than 1% of all neuroendocrine tumours. The aim of the paper is to present ten rare NETs from the database of the Endocrinology Department of the Jagiellonian University, Medical College: 4 NETs of the ampulla of Vater, 2 of the gallbladder, and 1 of the ovary, sphenoid sinus, Meckel's diverticulum, and epiglottis. The clinical presentation of such tumours and their management are discussed.

[Gastrointestinal tract polyps in acromegaly patients]

Acromegaly is a rare, chronic disease due to hypersecretion of growth hormone (GH) by pituitary adenoma arising from somatotrophs. The course of the disease is related to long-term organ and systemic complications and malignancies. Colon polyps seem to constitute the most frequent tumours in acromegaly apart from thyroid nodules. The aim of this study was to evaluate the prevalence of colon polyps in patients with acromegaly. Thirty one acromegaly patients, 22 females and 9 males (mean age 46.3 +/- 11.9 yrs), were enrolled to the study. Colonoscopy with histopathological assessment of specimens taken during examination was carried out in all patients. Colon polyps were found in 13 patients (41.9%) i.e. 8 females and 5 males. In two patients multiple polyps were discovered (2 and 3 respectively). Polyps were histopatologically verified as tubular adenoma with low-grade dysplasia (10 patients, 76.9%) and hyperplastic polyps (3 patients, 23.1%). The prevalence of colon polyps was significantly related to the duration of uncontrolled acromegaly (p < 0.01). Median duration of uncontrolled acromegaly in patients with and without colon polyps were 10.0 (IQR = 2.0) yrs and 6.5 (IQR = 5.0) yrs, respectively. IGF-1, GH basic and in 120 min of OGTT serum concentrations on diagnosis were not significantly related to the prevalence of colon polyps. Our study indicates that duration of uncontrolled acromegaly, contrary to IGF-1, GH basic and in OGTT serum concentrations at diagnosis are essential for the colon polyps development. Colonoscopy is considered to be routine in patients with acromegaly.

[Retrospective hormonal analysis of incidentally discovered and operated adrenal tumors for subclinical Cushing's syndrome]

In the last twenty years the introduction of new imaging techniques has caused increasing incidence of accidental detection of adrenal tumors, which are usually mild and in most cases are hormonally inactive adenomas. Among hormonal disorders in patients with adrenal incidentalomas the hypercortisolism is often described, which, if not treated properly, leads to multiple organ complications, and further to the patient's death. The aim of the study was the retrospective analysis of the group of patients with adrenal incidentaloma, verified by histopathology for assessment of subclinical Cushing's syndrome. Among the group of 225 patients: 62 men and 163 women with incidentally detected adrenal tumors in age from 19 to 81 years diagnosed and treated in the Department of Clinical Endocrinology, University Hospital in Krakow, 59 patients was sent to surgery: 15 men and 42 women. Two groups of patients were analysed, divided on the basis of histopathological examination result. Group A consisted of patients with adrenal cortical adenoma: 38 people (11 men and 27 women). In group B there were people with so-called other hormonal inactive adrenal tumors - 17 people (4 men and 13 women). The average age of the patients in group A was 52.05 +/- 11.52 years, in group B 51.44 +/- 14.14 years. In group A the mean morning level of cortisol was 18.23 +/- 6.42 ug/dl and did not differ statistically significantly from the results of group B (mean morning cortisol level of 15.86 +/- 4.6 ug/dl). However a significantly higher nocturnal cortisol levels in the blood serum of patients with group A versus group B was observed (6.78 +/- 5.65 ug/dl vs. 3.57 +/- 1.77 ug/dl). There was no cortisol diurnal rhythm disorders in group B, while in group A slightly disrupted cortisol diurnal rhythm was found in 17 people. Mean values of 24-hour urine 17-OHCS and free cortisol were statistically higher in group A than in group B, although mean values remained within normal limits. In 24 patients from group A where abnormalities in the screening test with 1 mg DXA were found, a test with 2 and 8 mg was performed, which showed incomplete suppression of the excretion of steroid metabolites in the urine after administration of 8 mg in 17 subjects, and 3 of the total absence of suppression. In group B in 4 people there was no suppression in 1 mg of DXA test, while the suppression test with 8 mg of DXA was normal. A detailed analysis of the clinical signs, meticulously carried out and repeated hormonal diagnosis with the use of functional tests should be focused on the detection of subclinical hormonal disorders, which is crucial in preventing organ damage and making a decision of the right treatment of the patient, which is surgical.

[The incidence of neoplasm in women using contraceptives]

Contraceptive is an important issue of women's life. In the present times there are many methods to prevent unwanted pregnancy. Each of them has its advantages and disadvantages and an appropriate choice of the method determines its promotion high efficiency and comfort its application. Today there is no method of contraception, which would not be charged some risk for the application. Following the review will allow literature to analyze impact of the various methods for the development of cancer control means diseases which may constitute a serious threat to health and life women.

[Diagnostic difficulties in recognizing of pheochromocytoma]

Pheochromocytoma (PH) is a tumour of chromaffin cells of the sympathetic nervous system and its clinical symptoms are associated with excessive production and release of catecholamines. The main criterion for clinical diagnosis of PH is finding increased concentrations of catecholamines or their metabolites in serum and/or urine. The largest diagnostic and therapeutic problems are patients with slightly elevated levels of methoxycatecholamines in serum and/ or urine. Aim of this study was to determine the cut-off point for elevated methoxycatecholamine in the collection of daily urine, which would give the basis for determining the reasonable recommendations of the biochemical criteria for diagnosis of PH. Retrospectively we analysed the results of 45 patients sent to laparoscopic adrenalectomy to the Department of General Surgery II with the preoperative diagnosis of pheochromocytoma. The diagnosis of pheochromocytoma was based on the finding of elevated 24-hour urine methoxycatecholamines. Based on the results of the histopathological examination patients were divided into two groups. Group 1 included 27 patients (14 women and 13 men) with histopathologically confirmed pheochromocytoma of adrenal gland. Group 2 consisted of 18 patients (11 women and 7 men), in which histopathological examination did not confirm the presence of pheochromocytoma. Mean age of patients in group 1: 46.8 +/- 14.4 years, in group 2: 55.7 +/- 13.7 years. Hypertension was diagnosed in 77.8% of those with group 1 and 94.4% from group 2. Based on the analyzed results of the CT, we found that the average tumor size in group 1 (4.2 +/- 1.9 cm) was statistically higher than in group 2 (2.9 +/- 1.1 cm). The average concentration of normetanephrine (NMN) in 24-hour urine in group 1 was statistically significantly higher than in group 2 (2,686 +/- 870.4 vs. 2375.1 +/- 754 mg/24h), as well as the average concentration of metanephrine (MN) (2533.4 +/- 3269.3 +/- 491.6 vs. 371.5 mg/24 hrs), and the sum of both methoxycatecholamines (NMN + MN) (5219.3 +/- 5190.6 vs. 1241.8 +/- 1202.2). The highest sensitivity in diagnosing pheochromocytoma with the rate of 81.5% was obtained for the sum of normetanephrine and metanephrine in 24-hour urine, while the sensivity for levels of each methoxycatecholamine separately was similar (63%). The highest specificity in the exclusion of PH was shown for 24-hour urine metanephrine (94.4%). The highest positive predictive value was found for the level of metanephrine in 24-hour urine (94.4%). The diagnostic cutoff concentrations of NMN, MN and NMN + MN for the diagnosis of pheochromocytoma were set. For the 24-hour urine NMN- cut-off > 1500 ug/24 h, for MN > 700 ug/24h and for NMN + MN > 1350 ug/24h. Shown above cut-off levels of methoxycatecholamines urine concentration will allow to pose a more accurate preoperative diagnosis of PH.

Adenomatoid tumour of the adrenal gland: a case report and literature review

Adenomatoid tumour (AT) is a rare, benign neoplasm of mesothelial origin, which usually occurs in the genital tract of both sexes. Occasionally these tumours are found in extra genital locations such as heart, pancreas, skin, pleura, omentum, lymph nodes, retroperitoneum, intestinal mesentery and adrenal gland. Histologically ATs show a mixture of solid and cystic patterns usually with focal presence of signet-ring like cells and scattered lymphoid infiltration. The most important thing about these tumours is not to mis-diagnose them as primary malignant or metastatic neoplasms. We present a case of an adrenal AT in a 29-year-old asymptomatic male. The tumour was an incidental finding during abdominal CT-scan for an unrelated condition. We also present a review of the literature concerning adrenal gland AT and give possible differential diagnosis.

The prevalence of benign and malignant neoplasms in acromegalic patients

INTRODUCTION

In acromegalic patients, the prevalence of certain benign and malignant neoplasms is higher than that in the healthy population. We retrospectively evaluated the prevalence of tumours in acromegalic patients treated at our department: the regional centre for acromegalic patients for the Małopolskie voivodeship in Poland.

MATERIAL AND METHODS

During the years 1983-2008, a hundred and one acromegalic patients (30 males and 71 women), of mean age 51.8 +/- 15.4 years, were diagnosed and treated. Pituitary macroadenoma and microadenoma were stated in 63.4% and 25.7% of these patients, respectively. In 10.9% of these patients no data on tumour diameter were available. The mean observation period was 9.4 +/- 6.5 years. The median levels of hGH and IGF-1 prior to neurosurgery were 20.2 (IQR = 34.9) ng/ml and 764.5 (IQR = 569.6) ng/ml, respectively.

RESULTS

In the studied group of patients, we found the following prevalence of various tumours: nodular goitre - 64/101 patients (63.0%), polyps of the colon - 13/101 patients (13.0%); uterine polyps - 4/101 patients (4.0%); and prostate adenoma - 2/101 patients (2.0%). Among malignant tumours, thyroid cancer, endometrium and cervix cancer were the most frequent, each of these occurring in 3 patients (3.0%). Colon cancer prevalence was 2.0% (in 2 patients).

CONCLUSIONS

From our retrospective study, we suggest an overall increase of tumour incidence in acromegalic patients. Prospective multicentre studies are required to resolve the significance of this observation. In our study group, the number of malignant neoplasms was significantly higher in patients with long-lasting uncontrolled disease (over 5 years), compared to patients with controlled disease. (Pol J Endocrinol 2010; 61 (1): 29-34).

[Quantitative analysis of heart scintigraphy (99mTc-MIBI GSPECT) with regional myocardial wall motion and systolic thickening of left ventricle assessment for detecting myocardial damage in ethanol withdrawal patients]

Severe ethanol withdrawal syndrome, with psychosomatic symptoms, is life-threatening condition and if not treated can be fatal (in approximately 15% of cases). The purpose of this investigation was to assess cardiac muscle function using 99mTc-MIBI GSPECT in acute alcohol withdrawal. The group examined consisted of 10 males aged from 33 to 45 (45.7 +/- 8.82) because of alcohol withdrawal syndrome. The control group for quantitative analysis of the heart scintigraphy (GSPECT) consisted of 20 people referred for examination to the Laboratory of Nuclear Medicine, Jagiellonian University, which results of cardiac perfusion scintigraphy were assessed as normal. In acute withdrawal syndrome quantitative analysis of the heart scintigraphy (99mTc-MIBI GSPECT) revealed impaired regional wall motion and wall thickening related mainly to the lower wall segments. The abnormalities in myocardial perfusion (99mTc-MIBI GSPECT) was found in varying degrees of severity in all patients.

Iodine-deficiency prophylaxis and the restriction of salt consumption - a 21st century challenge

The World Health Organization (WHO) issued a recommendation (Technical Consultation: Paris 2006, Luxembourg 2007) that salt consumption, as a risk factor for hypertension, atherosclerosis, myocardial infarction, stroke, and select cancers, should be restricted. The European Commission looked to adhere to this recommendation by creating the High Level Group on Nutrition and Physical Activity. According to WHO recommendations, a daily allowance of 5 g NaCl (i.e., 2 g Na) for individual salt consumption should not be exceeded. At present, mean individual salt consumption in Poland totals 13.5 g, of which salt used in household constitutes 8.8 g. In some regions of Poland, this number reaches upwards of 15.0 g/person. The Position Paper on Initiatives Aimed at Decreasing Salt Consumption in Poland, developed by an expert group at the National Food and Nutrition Institute, set the course for intervention, including changing recipes for massproduced food products and large-scale catering, improving oversight by food control agencies, and continuing legislative changes. These interventions should also include education directed towards consumers, food producers, public health professionals, healthcare workers, and media representatives. The Position Paper of the Polish Hypertension Society also sets the course for promoting restricted salt consumption and controlling hypertension on a population level. However, household salt is the main carrier of iodine in the Polish model of iodine prophylaxis. Thus, any interventions also require synchronized action with the Polish Council for Control of Iodine Deficiency Disorders. Current efforts aimed at preventing iodine-deficiency look to increase consumption of other iodine-rich products (e.g., milk, mineral water) with standardized levels of iodine. Once they achieve an iodine concentration of 0.1-0.2 mg, these products can easily supplement any decrease in physiological iodine levels resulting from reduced salt consumption. Also required are wide-ranging educational campaigns which will be coordinated by the new designated WHO Collaborating Centre for Nutrition at the Chair of Endocrinology at Jagiellonian University, Collegium Medicum in Kraków. (Pol J Endocrinol 2010; 61 (1): 135-140).