A Robust Initialization of Residual Blocks for Effective ResNet Training Without Batch Normalization

Batch normalization is an essential component of all state-of-the-art neural networks architectures. However, since it introduces many practical issues, much recent research has been devoted to designing normalization-free architectures. In this brief, we show that weights initialization is key to train ResNet-like normalization-free networks. In particular, we propose a slight modification to the summation operation of a block output to the skip-connection branch, so that the whole network is correctly initialized. We show that this modified architecture achieves competitive results on CIFAR-10, CIFAR-100 and ImageNet without further regularization nor algorithmic modifications.

Modeling cancer drug response through drug-specific informative genes

Recent advances in pharmacogenomics have generated a wealth of data of different types whose analysis have helped in the identification of signatures of different cellular sensitivity/resistance responses to hundreds of chemical compounds. Among the different data types, gene expression has proven to be the more successful for the inference of drug response in cancer cell lines. Although effective, the whole transcriptome can introduce noise in the predictive models, since specific mechanisms are required for different drugs and these realistically involve only part of the proteins encoded in the genome. We analyzed the pharmacogenomics data of 961 cell lines tested with 265 anti-cancer drugs and developed different machine learning approaches for dissecting the genome systematically and predict drug responses using both drug-unspecific and drug-specific genes. These methodologies reach better response predictions for the vast majority of the screened drugs using tens to few hundreds genes specific to each drug instead of the whole genome, thus allowing a better understanding and interpretation of drug-specific response mechanisms which are not necessarily restricted to the drug known targets.

First molecular and serological detection of Epizootic Hemorrhagic Disease virus in white tailed deer ( Odocoileus virginianus ) from Tamaulipas, Mexico

ABSTRACT Epizootic hemorrhagic disease viruses (EHDV) are dsRNA arboviruses transmitted by biting midges of the genus Culicoides that cause disease in domestic and wild ruminants. Epizootic hemorrhagic disease (EHD) is considered the most important infectious disease of white tailed deer (WTD) in North America, some studies in Northeast Mexico reported EHDV-seropositive WTD and EHDV-infected Culicoides vectors. The increasing population of WTD that share habitat with livestock in Northeast México highlights the importance of EHD for the livestock industry in the transboundary region with the U.S. One hundred and twenty two samples from WTD in Tamaulipas state, Mexico were tested by ELISA and RT-PCR for EHDV antibodies and nucleic acid, respectively. Twelve animals were seropositive to ELISA and eleven animals were positive by RT-PCR. This is the first report of EHDV nucleic acid detection in WTD from Mexico. It is hypothesized that applying the transboundary disease approach to interdisciplinary research will help fill knowledge gaps, which could help develop countermeasures to mitigate the threat of EHDV infection in wildlife and livestock along the U.S.-Mexico border.

Biomarkers of erosive arthritis in systemic lupus erythematosus: Application of machine learning models

OBJECTIVE

Limited evidences are available on biomarkers to recognize Systemic Lupus erythematosus (SLE) patients at risk to develop erosive arthritis. Anti-citrullinated peptide antibodies (ACPA) have been widely investigated and identified in up to 50% of X-ray detected erosive arthritis; conversely, few studies evaluated anti-carbamylated proteins antibodies (anti-CarP). Here, we considered the application of machine learning models to identify relevant factors in the development of ultrasonography (US)-detected erosive damage in a large cohort of SLE patients with joint involvement.

METHODS

We enrolled consecutive SLE patients with arthritis/arthralgia. All patients underwent joint (DAS28, STR) and laboratory assessment (detection of ACPA, anti-CarP, Rheumatoid Factor, SLE-related antibodies). The bone surfaces of metacarpophalangeal and proximal interphalangeal joints were assessed by US: the presence of erosions was registered with a dichotomous value (0/1), obtaining a total score (0-20). Concerning machine learning techniques, we applied and compared Logistic Regression and Decision Trees in conjunction with the feature selection Forward Wrapper method.

RESULTS

We enrolled 120 SLE patients [M/F 8/112, median age 47.0 years (IQR 15.0); median disease duration 120.0 months (IQR 156.0)], 73.3% of them referring at least one episode of arthritis. Erosive damage was identified in 25.8% of patients (mean±SD 0.7±1.6), all of them with clinically evident arthritis. We applied Logistic Regression in conjunction with the Forward Wrapper method, obtaining an AUC value of 0.806±0.02. As a result of the learning procedure, we evaluated the relevance of the different factors: this value was higher than 35% for ACPA and anti-CarP.

CONCLUSION

The application of Machine Learning Models allowed to identify factors associated with US-detected erosive bone damage in a large SLE cohort and their relevance in determining this phenotype. Although the scope of this study is limited by the small sample size and its cross-sectional nature, the results suggest the relevance of ACPA and anti-CarP antibodies in the development of erosive damage as also pointed out in other studies.

Anaphylaktischer Schock nach wiederholter Injektion von 99mTc-markiertem CEA-Antikörper

Bei einem 64jährigen Patienten mit Rezidiv eines Rektumkarzinoms wurden im Abstand von 14 Monaten zwei Immunszintigraphien mit 99mTc-markiertem CEA-Antikörper (BW 431/26) durchgeführt. Bei der zweiten Untersuchung trat wenige Minuten nach der Injektion ein anaphylaktischer Schock auf, der mit Epinephrin und Kortison zu beherrschen war. Nach unserem Wissen handelt es sich um die Erstbeschreibung einer schweren Nebenwirkung bei diesem monoklonalen Antikörper. Die Testung auf Human Anti-Mouse Antibodies vor der Zweitinjektion war mit einer Methode negativ, mit einer anderen Methode positiv.

Detection of melanoma metastases With Tc-99m-tetrofosmin

Aim: The aim of this study was to evaluate Tc-99mtetrofosmin whole-body imaging in the detection of metastases in patients with malignant melanoma. Methods: In 30 patients with suspected melanoma metastases we performed whole body imaging. After administration of about 600 MBq Tc-99m-tetrofosmin dynamic images up to 10 min were performed in 7 patients (1 image per 10 sec) to evaluate the optimal tracer uptake in the metastases. In all patients whole-body images were performed 5-10 min p. i. using an acquisition time of 5 min per image. The final diagnosis was confirmed by surgical histology in 30 lesions, by computertomogaphy and clinical course in the remaining lesions. Results: Out of 64 melanoma metastases 49 were detected using Tc-99m-tetrofosmin scintigraphy (49 rp., 15 fn.). The overall sensitivity for the detection of malignant lesions was 77%. Referring only to the lymph node metastases, the sensitivity was 87% (26 rp.; 4 fn.). The maximal tracer uptake was reached 1 min after injection, with a slow decrease in the following 10 minutes. The size of the lesions ranged between 0.5 and 7.0 cm and the T/B ratios between 1.3 and 3.0 (mean 1.88). Conclusions: Tc-99m-tetrofosmin whole body imaging is a simple and side-effectless method for the detection of melanoma metastases especially of lymph node metastases. The results are comparable to Tc-99m-sestamibi and TI-201 scintigraphy.

Lymphoscintigraphy in breast cancer patients –comparison of peritumoural and intradermal injection

Aim of this study was to determine whether the sentinel lymph nodes (SLNs) can be accurately identified in breast cancer patients with intradermal injection of the radiotracer above the primary tumour in comparison to peritumoural injection. Methods: In 45 women with breast cancer we performed lymphoscintigraphy on two separate days. We injected Tc-99m nanocolloid on the first day peritumourally, and on a separate day intradermally. The results of both investigations using different injection sites were compared in order to determine the number and location of SLNs. Results: The SLN identification rate using peritumoural injection was 71% (32 of 45 patients) and 96% (43 out of 45 patients) using intradermal injection. In 62% (28 of 45 patients) the number and location of the SLNs were identical. In 97% (31 of 32 patients) in whom a SLN was detected using peritumoural injection, the same SLNs reappeared with intradermal injection. There were no false negative findings with the peritumoural administration of tracer whereas the intradermal administration approach resulted in a false negative rate of 13%. Conclusion: In women with breast cancer the reproducibility of lymphoscintigraphy using peritumoural and intradermal injection sites was 62%. The intradermal injection modality enables the detection of a SLN in patients where the peritumoural injection failed but it has the disadvantage of a higher false negative rate in comparison to the peritumoural injection technique.

Prediction of chronic damage in systemic lupus erythematosus by using machine-learning models

Objective

The increased survival in Systemic Lupus Erythematosus (SLE) patients implies the development of chronic damage, occurring in up to 50% of cases. Its prevention is a major goal in the SLE management. We aimed at predicting chronic damage in a large monocentric SLE cohort by using neural networks.

Methods

We enrolled 413 SLE patients (M/F 30/383; mean age ± SD 46.3±11.9 years; mean disease duration ± SD 174.6 ± 112.1 months). Chronic damage was assessed by the SLICC/ACR Damage Index (SDI). We applied Recurrent Neural Networks (RNNs) as a machine-learning model to predict the risk of chronic damage. The clinical data sequences registered for each patient during the follow-up were used for building and testing the RNNs.

Results

At the first visit in the Lupus Clinic, 35.8% of patients had an SDI≥1. For the RNN model, two groups of patients were analyzed: patients with SDI = 0 at the baseline, developing damage during the follow-up (N = 38), and patients without damage (SDI = 0). We created a mathematical model with an AUC value of 0.77, able to predict damage development. A threshold value of 0.35 (sensitivity 0.74, specificity 0.76) seemed able to identify patients at risk to develop damage.

Conclusion

We applied RNNs to identify a prediction model for SLE chronic damage. The use of the longitudinal data from the Sapienza Lupus Cohort, including laboratory and clinical items, resulted able to construct a mathematical model, potentially identifying patients at risk to develop damage.

Abstract P4-04-03: Obesity-induced EMT in luminal A breast cancer cells

Introduction: Obesity is associated with a worse prognosis in breast cancer, including the less aggressive ER+ luminal A subtype, but the mechanisms by which it promotes disease progression are unclear, making treatment difficult. Obese breast cancer patients have a higher risk of a more aggressive disease compared to lean patients, which is associated with treatment resistance and metastasis. The mechanisms promoting obesity-driven metastasis are not understood, but several studies have indicated that obesity is associated with a “stem-like” phenotype. A “reprogramming” occurs, transforming stationary, epithelial cells to motile, malignant cells that exhibit a more aggressive phenotype than their stromal counterparts. Our data suggest that in vitro exposure of luminal A breast cancer cells to obese conditions may induce an epithelial to mesenchymal transition (EMT), which is characterized by a more stem-like phenotype, resistance to treatment (chemo, hormone and radiation), as well as greater metastatic potential. This has let us to hypothesize that one critical mechanism by which obesity promotes a more aggressive disease is through inducing an EMT reprogramming, resulting in a more stem-like phenotype.

Methods and Results: Both in vitro and translational approaches will be done to determine if obesity induces epigenetic reprograming associated with a more stem-like phenotype. MCF-7 ER+ breast cancer cells exposed to 2% sera from obese (BMI ≥ 30) postmenopausal women demonstrated a significant increase in expression of both SNAIL1 and TWIST transcription factors (9-fold and 4-fold, respectively) which are implicated in EMT and potentially stem-cell programming, compared to those exposed to sera from lean women. Current studies are underway to determine if this is observed in other ER+ luminal A cell lines, including T47D, and whether induced changes in these transcription factors results in changes in signaling pathways associated with EMT, including TGFβ, which can activate the PI3K–AKT, ERK MAPK, p38 MAPK and JNK pathways and WNT signaling, which promotes EMT by stabilizing β-catenin. Additionally, the luminal A cell lines will be assessed for changes in other factors known to modulate breast cancer cell programming, including KLF4, OCT4, SOX2, and NANOG.

Conclusions: Our earlier studies have demonstrated that obesity promotes a more aggressive disease even in luminal A disease. The mechanisms for this remain unclear. Our exciting preliminary findings suggest that obesity might induce a reprogramming of the luminal A well-differentiated cell to a more stem-like phenotype. Our results will lay an important foundation for understanding how obesity modulates breast cancer disease progression, whether this programming may provide therapeutic target to improve response and overall survival in the obese patient.

Citation Format: Hayden A, Quach D, Galvan G, Patodia R, Brenner A, deGraffenried L. Obesity-induced EMT in luminal A breast cancer cells [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P4-04-03.

Abstract P6-17-03: The importance of the ultimate ratio of Omega-6 to Omega-3 fatty acids in the efficacy of fish oil supplements in suppressing inflammation in obese postmenopausal women

Over the last decade, a large body of evidence has established that obesity is associated with a worse breast cancer prognosis for both pre- and postmenopausal women. There are several mechanisms which have been proposed for promoting this effect, including stage of diagnosis and co-morbidities, but more recent evidence suggests that the obese state is associated with changes in the biology of the disease, promoting a more aggressive phenotype. Our recently published in vitro and retrospective studies suggest that this is due, at least in part, through cyclooxygenase 2 (COX-2)-derived prostaglandin E2 (PGE2), and that interventions that suppress COX-2 PGE2 production may provide significant benefit for the obese ER+ patient in preventing many of the cancer-promoting effects associated with obesity. Omega-3 fatty acids have demonstrated anti-cancer benefit through multiple mechanisms, including suppression of inflammation-related signaling. DHA and EPA (omega-3 PUFAs found in fish oil) modulate inflammatory responses through COX-2 dependent and independent mechanisms. However, previous studies investigating the potential anti-cancer benefit of omega-3 PUFA and fish oil supplementation have produced mixed results, and none have focused specifically on the obese patient population.

To determine if supplementation with non-steroidal anti-inflammatory drugs (NSAIDs), including omega-3 fatty acids, can effectively suppress PGE2 production in the obese postmenopausal patient, we conducted a double-blind, prospective Phase 0, comparative, 30 day, non-interventional study with correlative biomarker endpoints. One hundred twenty (120) postmenopausal women without breast cancer were randomized to three arms 1. ASA 81mg po daily, 2. 1500mg of docosahexaoic acid (DHA) and 2500mg eicosapentanoic acid (EPA) given daily and 3. Combined ASA and DHA/EPA at above doses. Serum samples were collected prior to and on day 29 of taking the supplements. PGE2 levels in the pre- and post-supplement serum samples were analyzed in triplicate by ELISA and presented as the percentage of change between post- and pre-supplement levels. Of the women in Arm 2 (DHA + EPA only), only 55% demonstrated a significant suppression of PGE2 levels after 30 day of supplements, compared to those in Arm 1 (ASA), in which 80% demonstrated a significant response.

We anticipate that the omega-3 fatty acid supplements were not as effective in as large a population as the aspirin due to a failure to reach a critical ratio between circulating levels omega-6 and omega-3 fatty acids, which has been shown by our own group and others to be a key determinant of cellular response. Studies are on-going to analyze the PUFA levels in both the pre and post supplement serum samples, and pre-clinical studies are being conducted to determine if the ratio of omega-6 to omega-3 PUFAs modulates PGE2 production in several different cell types, including macrophages, adipocytes and the breast cell itself. These results will be critical for moving clinical studies utilizing these agents forward, both in terms of elucidating the mechanism mediating an effect, and also in identifying an accurate biomarker for monitoring compliance and response.

Citation Format: Quach D, Lengfelder L, Winnika L, Harlow B, Galvan G, Jolly C, Brenner A, deGraffenried L. The importance of the ultimate ratio of Omega-6 to Omega-3 fatty acids in the efficacy of fish oil supplements in suppressing inflammation in obese postmenopausal women [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P6-17-03.

Evaluation of Bone Mineral Density in Patients with Type 1 Gaucher Disease in Argentina

The purpose of this study was to evaluate the frequency of osteoporosis (OP) in patients with Gaucher disease (GD) in Argentina. GD patients from 28 centers were consecutively included from April 2012 to 2014. Bone mineral density (BMD) was determined by dual X-ray absorptiometry in the lumbar spine and the femoral neck or the total proximal femur for patients ≥20 yr of age, and by whole-body scan in the lumbar spine in patients <20 yr of age. In children, mineral density was calculated using the chronological age and Z height. OP diagnosis was determined following adult and pediatric official position of the International Society for Clinical Densitometry. A total of 116 patients were included, of which 62 (53.5%) were women. The median age was 25.8 yr. All patients received enzyme replacement therapy, with a median time of 9.4 yr. Normal BMD was found in 89 patients (76.7%), whereas low bone mass (LBM) or osteopenia was found in 15 patients (13%) and OP in 12 patients (10.3%). The analysis of the pediatric population revealed that 4 patients (9.3%) had LBM and 3 (7%) had OP (Z-score ≤ -2 + fractures height-adjusted by Z), whereas in the adult population (n = 73), 11 patients (15%) had LBM or osteopenia and 9 (12.3%) had OP. Bone marrow infiltration and the presence of fractures were significantly correlated with the presence of OP (p = 0.04 and <0.001, respectively). This is the first study in Argentina and in the region describing the frequency of OP or LBM in GD patients treated with imiglucerase using the official position of the International Society for Clinical Densitometry.

Regression of rat Dunning R-3327-H prostate carcinoma by treatment with targeted cytotoxic analog of luteinizing hormone-releasing hormone AN-207 containing 2-pyrrolinodoxorubicin

The effects of AN-207, a new targeted cytotoxic analog of LH-RH, were evalued in rats bearing hormone-dependent Dunning R-3327-H prostate carcinomas. AN-207 consists of the agonist [D-Lys(6)]LH-RH linked to 2-pyrrolino-doxorubicin, an intensely potent derivative of doxorubicin. In the first experiment, 2-pyrrolinodoxorubicin was administered at a concentration of 50 nmol/kg, as a single drug (AN-201) and as an unconjugated mixture with [D-Lys(6)]LH-RH or conjugated to the carrier [D-Lys(6)]LH-RH (AN-207). Following the second administration of radical AN-201 alone or mixed with the carrier, all rats died with signs of general toxicity, but all animals treated with the conjugate AN-207, survived. After 5 weeks of treatment with a total dose of 150 nmol/kg AN-207, the tumors regressed from an initial volume of 8.35 +/- 1.7 cm(3) to 4.47 +/- 0.8 cm(3), while tumors in the control group measured 17.84 +/- 2.2 cm(3). The therapy with AN-207 also significantly reduced tumor weight and tumor burden. In the second experiment, we compared the efficacy and toxicity of 3 injections of 25 nmol/kg AN-201 or 25 nmol/kg and 50 nmol/kg AN-207. The initial tumor volume in all groups was between 3.9 and 4.5 cm(3). After 5 weeks of therapy, the tumors of rats treated with 50 nmol/kg AN-207 regressed to 2.3 +/- 0.51 cm(3), whereas 25 nmol/kg AN-201 was still toxic in contrast to 25 nmol/kg AN-207, while the reduction in final tumor volume was similar (6.76 +/- 1.4 cm(3) and 6.74 +/- 1 cm(3), respectively), as compared to 15.6 +/- 2.2 cm(3) for untreated animals. High capacity LH-RH receptors were found in the membranes of untreated Dunning tumor specimens, but after treatment with AN-207, they could no longer be detected. This is the first demonstration that the new targeted cytotoxic LH-RH analog AN-207 is an effective antitumor agent. Our work indicates that the cytotoxic analog AN-207 is much less toxic than the antineoplastic radical (AN-201) incorporated, and significantly more active in inhibiting tumor growth. Further development of approaches based on targeted cytotoxic analog AN-207 may lead to major improvements in current palliative therapy of prostate cancer.

Cholesteryl ester transfer protein TaqIB polymorphism and its relation to parameters of the insulin resistance syndrome in an Austrian cohort

The cholesteryl ester transfer protein (CETP) is responsible for the exchange of triglycerides and cholesteryl esters between lipoprotein particles leading to an increased hepatic clearance of HDL-cholesteryl esters. A high CETP activity reduces serum HDL levels, whereas persons without CETP activity have high HDL levels. We investigated the association of the TaqIB CETP polymorphism and various parameters of the insulin resistance syndrome in a cross sectional population based study. We included 1029 persons without known cardiovascular disease or diabetes mellitus consecutively enrolled in our SAPHIR program (Salzburg Atherosclerosis Prevention program in persons with a High Infarction Risk). Numerous clinical and laboratory data were accomplished. Insulin sensitivity was measured by a short insulin tolerance test. The TaqIB CETP polymorphism was determined by PCR, TaqI restriction and electrophoresis. 35.2% were homozygous for the prevalence (B1B1), 46.7% were heterozygous (B1B2), and 18.1% homozygous for the absence (B2B2) of the restriction site. HDL cholesterol and apolipoprotein A1 were lower and small dense low-density lipoproteins (sdLDL) higher in B1B1 compared to B2B1 and B2B2 persons. In women, we found a significant interaction effect between CETP genotype and adiposity for HDL cholesterol. B1B1 women with a BMI and a waist circumference above the median had 9.7 mg/dl lower HDL than B1B2 and 9.1 mg/dl lower HDL than B2B2 women (P < 0.001). In men, no interaction effect but a marked genotype to HDL correlation was found. There was a high CETP effect on sdLDL detected in men (P = 0.001). B1B1 men had sdLDL in 36%, B1B2 in 24.6%, and B2B2 in only 14.5%. Men with adiposity and insulin resistance had twice as many sdLDL as insulin sensitive men. We found a significant sex specific effect of the TaqIB CETP polymorphism on the insulin resistance parameters HDL-cholesterol and sdLDL in an Austrian population based study.

Antibodies to heat-shock protein 65 and neopterin levels in patients with type 1 diabetes mellitus

Antibodies to heat shock protein (hsp) are strongly associated with atherosclerotic cardiovascular disease in the non-diabetic population as well as in patients with type 2 diabetes mellitus. In type 1 diabetes increased antibody titers to hsp were found to be a symptom of the autoimmune disease leading to beta-cell damage. We asked whether hsp antibody titers are related to metabolic control and late complications in type 1 diabetic patients. Serum neopterin, also an indicator of chronic inflammation, was also evaluated. The hsp65 antibody titer was determined in 138 patients with type 1 diabetes, 47 women and 91 men, aged 35.5 +/- 12 years with a mean diabetes duration of 16.6 +/- 10.5 years. A history of diabetic late complications and cardiovascular disease was taken. A fundoscopy and a neurological examination were performed, nephropathy was assessed by measurement of the urinary albumin excretion rate. For the measurement of the hsp antibody titer an enzyme-linked immunosorbent assay (ELISA) was applied, for neopterin a radio-immuno assay (RIA) was used. The hsp65 antibody titer was found to be positively related to the patients' age (r = 0.237; p < 0.035). Patients with retinopathy revealed significantly higher hsp65 antibody titers (307.2 +/- 38.6) than those without retinopathy (150.0 +/- 18.5;p < 0.003). No correlation was found between hsp antibody titer and metabolic control. Serum neopterin levels revealed a trend towards a positive relationship with diabetes duration (r = 0.205; p < 0.0539) and a significant correlation with serum cholesterol levels (r = 0.436; p < 0.001), but not with HbA1 c values. Our data add further information to the role of inflammatory markers in the development of diabetic microangiopathy.

Reproducibility of lymphoscintigraphy in cutaneous melanoma: can we accurately detect the sentinel lymph node by expanding the tracer injection distance from the tumor site?

The aim of the study was to determine whether the sentinel lymph node (SLN) can be accurately detected in cutaneous melanoma patients when the injection distance from the tumor site is expanded.

METHODS

In 100 patients with cutaneous melanoma, lymphoscintigraphy was performed twice. First, we injected 37 MBq (99m)Tc nanocolloid intracutaneously at a 2- to 5-mm distance from either the melanoma or the biopsy scar. The injection was followed by dynamic imaging, which continued until the SLN became visible. On another day, we repeated the investigation, injecting the radiopharmaceutical intracutaneously exactly 10 mm from the previous injection site. The detected SLNs of both investigations were compared to determine the number and location of SLNs for each patient.

RESULTS

The SLN identification rate was 94% with close injection and 100% with 10-mm-distant injection. All SLNs detected with close injection were visible with distant injection. In 84 of 100 patients, the images of both investigations showed the same number and location of SLNs. In the remaining 16 patients, an additional SLN was detected with the distant injection.

CONCLUSION

The reproducibility of lymphoscintigraphy using different injection distances was 84%. The discordance in the remaining 16% was caused by detection of a lymph node in addition to the original SLN with distant injection. Diagnostic excision of the primary tumor before lymphoscintigraphy was possible without preventing detection of the original SLN. However, in 16% of our patients, excision of an additional lymph node had to be considered when lymphoscintigraphy was performed after diagnostic excision.

Malignant glioma as a secondary malignant neoplasm after radiation therapy for craniopharyngioma: report of a case and review of reported cases

BACKGROUND

The development of a secondary neoplasm in childhood cancer survivors attains growing importance due to the reported excellent survival and therefore the long exposure to potentially carcinogenic effects of treatment.

CASE REPORT

We report a 14-year-old girl in whom a large craniopharyngioma (CP) was diagnosed. After surgery, radiation therapy (RT) was given for residual tumour. Discrete progression necessitated further surgery, resulting in permanent tumour control. Soon after the second surgery hypothalamic-pituitary dysfunction developed together with obesity. Supportive hormone therapy was initiated. Growth hormone (GH) therapy was also given for 15 months. Four years after the diagnosis, a cerebropontine anaplastic astrocytoma WHO grade III was detected, with the main lesion being at the dorsal edge of the irradiated area. The girl died 1 month later from this secondary presumably radiation-induced tumour. Only recently a second child with RT for a CP was diagnosed with malignant glioma in our hospital. CASE REPORTS IN THE LITERATURE: 12 other cases of malignant glioma have been reported after RT for CP. Including our present cases, the mean latency period was 10.7 years (median 9.6 years). However, the shortest latency periods were found in patients who had received GH therapy. In numerous cases, the secondary tumour was seen at the edge of the irradiated volume, and not in the region with the highest absorbed dose.

CONCLUSIONS

Therapy-induced secondary gliomas after treatment of CP or other intracranial tumours are rare but dramatic late events with a very poor prognosis. Including our own 2 patients, we reviewed 14 cases of CP with occurrence of a secondary, probably radiation-induced malignant glioma. The short latency periods for patients treated with GH is remarkable. We therefore suspect that GH therapy may accelerate the development of a secondary brain tumour. We are reluctant to recommend GH therapy in conventionally irradiated CP patients. In order to seriously answer the questions about therapy-induced secondary neoplasms, a life-long follow-up is mandatory for all patients who are survivors of childhood cancer.

Whole-body scintigraphy in melanoma patients: comparison of 99Tcm-tetrofosmin and 201Tl

The aim of this study was to determine the diagnostic value of 99Tcm-tetrofosmin whole-body imaging in comparison to 201Tl scintigraphy in patients with metastatic melanoma. In 27 patients with known or suspected melanoma metastases we performed 201Tl scintigraphy and 99Tcm-tetrofosmin scintigraphy using a 1-day protocol. In five patients with known locoregional metastasis the in vivo uptake kinetics of both radiotracers were compared. The final diagnosis was confirmed by surgical histology in 39 lesions (group I) and computed tomography (CT) and clinical course in 14 lesions (group II). In group I, containing mainly locoregional metastases, 201Tl scintigraphy correctly identified 36 of 39 metastases and 99Tcm-tetrofosmin 35 of 39 resulting in a sensitivity of 92% and 90% respectively. The T/B ratios of 201Tl (1.4-4.0, mean 2.15) were statistically significantly higher in comparison to tetrofosmin (1.3-3.0, mean 1.88). However, both radiotracers showed similar uptake and washout kinetics with a maximum of tracer uptake between 1 and 5 min p.i. In group II, containing mainly cerebral and pulmonary metastases, both methods correctly identified six of 14 metastases resulting in a sensitivity of only 43%. We conclude that the uptake of 99Tcm-tetrofosmin and 201Tl in melanoma metastases is very similar. The T/B ratios with 99Tcm-tetrofosmin are significantly lower than with 201Tl. In locoregional melanoma metastases the sensitivity of tetrofosmin scintigraphy is identical with 201Tl imaging and amounts to 90%. In cerebral and lung metastases the sensitivity of both methods is limited when using whole-body scintigraphy.

Lymphoscintigraphy in breast cancer patients--comparison of peritumoural and intradermal injection

AIM of this study was to determine whether the sentinel lymph nodes (SLNs) can be accurately identified in breast cancer patients with intradermal injection of the radiotracer above the primary tumour in comparison to peritumoural injection.

METHODS

In 45 women with breast cancer we performed lymphoscintigraphy on two separate days. We injected Tc-99m nanocolloid on the first day peritumourally, and on a separate day intradermally. The results of both investigations using different injection sites were compared in order to determine the number and location of SLNs.

RESULTS

The SLN identification rate using peritumoural injection was 71% (32 of 45 patients) and 96% (43 out of 45 patients) using intradermal injection. In 62% (28 of 45 patients) the number and location of the SLNs were identical. In 97% (31 of 32 patients) in whom a SLN was detected using peritumoural injection, the same SLNs reappeared with intradermal injection. There were no false negative findings with the peritumoural administration of tracer whereas the intradermal administration approach resulted in a false negative rate of 13%.

CONCLUSION

In women with breast cancer the reproducibility of lymphoscintigraphy using peritumoural and intradermal injection sites was 62%. The intradermal injection modality enables the detection of a SLN in patients where the peritumoural injection failed but it has the disadvantage of a higher false negative rate in comparison to the peritumoural injection technique.

Detecting the sentinel lymph node in patients with differentiated thyroid carcinoma

The aim of this study was to evaluate sentinel lymph node mapping in patients with differentiated thyroid carcinoma. Nine patients with suspected thyroid carcinoma who were scheduled to undergo thyroidectomy underwent scintigraphic localization of sentinel lymph nodes (SLNs). On the day of surgery we injected 37 MBq technetium-99m nanocolloid intratumourally. Dynamic data up to 10 min followed by planar anterior and lateral oblique images up to 1 h after tracer administration were recorded. At surgery the primary tumour was excised first, then the SLNs were removed using a gamma probe. Four patients had papillary carcinoma, two follicular carcinoma, one an oncocytic tumour and two benign tumours. An SLN was identified in all four patients with papillary carcinoma. In the two patients with follicular carcinoma, SLN detection failed. Five patients had one radioactive node, one had three and one had four. In one patient, no SLN was visible with scintigraphic imaging but at surgery three SLNs could be clearly identified using the gamma probe after removal of the primary tumour. There were no false-negative findings. This initial study indicates that in patients with papillary thyroid carcinoma detection of the SLN is possible, whereas the technique failed in two patients with follicular carcinoma. A study on a larger patient sample is now warranted.

Serodiagnosis of recently acquired Toxoplasma gondii infection using an enzyme-linked immunosorbent assay with a combination of recombinant antigens

An enzyme-linked immunosorbent assay (ELISA) using four recombinant antigens of Toxoplasma gondii (rP22, rP25, rP29, and rP35) was used in an attempt to differentiate pregnant women with toxoplasma serologic profiles (TSPs) indicative of recently acquired infections (acute profile) from those with TSPs indicative of infections acquired in the distant past (chronic profile). In general, immunoglobulin G antibodies in sera from women with the acute profile reacted more strongly with the recombinant antigens than did those in sera from women with the chronic profile. However, reactivities differed significantly between antigens that reacted with a single serum and between sera that reacted with a single antigen. Because of these variations, we employed a combination of the four antigens in an ELISA (Comb-ELISA) and evaluated its ability to distinguish pregnant women with the acute profile from those with the chronic profile. Eighteen of 20 (90%) sera from acute-profile women were positive in the Comb-ELISA, whereas 69 of 70 (98.6%) sera from the chronic-profile women were negative. Thus, the Comb-ELISA may be useful for diagnosis of toxoplasmosis in pregnant women and for differentiation between recently acquired infections and infections acquired in the more distant past.

[Detection of melanoma metastases with Tc-99m-tetrofosmin]

AIM

The aim of this study was to evaluate Tc-99m-tetrofosmin whole-body imaging in the detection of metastases in patients with malignant melanoma.

METHODS

In 30 patients with suspected melanoma metastases we performed whole body imaging. After administration of about 600 MBq Tc-99m-tetrofosmin dynamic images up to 10 min were performed in 7 patients (1 image per 10 sec) to evaluate the optimal tracer uptake in the metastases. In all patients whole-body images were performed 5-10 min p.i. using an acquisition time of 5 min per image. The final diagnosis was confirmed by surgical histology in 30 lesions, by computertomography and clinical course in the remaining lesions.

RESULTS

Out of 64 melanoma metastases 49 were detected using Tc-99m-tetrofosmin scintigraphy (49 rp., 15 fn.). The overall sensitivity for the detection of malignant lesions was 77%. Referring only to the lymph node metastases, the sensitivity was 87% (26 rp.; 4 fn.). The maximal tracer uptake was reached 1 min after injection, with a slow decrease in the following 10 minutes. The size of the lesions ranged between 0.5 and 7.0 cm and the T/B ratios between 1.3 and 3.0 (mean 1.88).

CONCLUSIONS

Tc-99m-tetrofosmin whole body imaging is a simple and side-effectless method for the detection of melanoma metastases especially of lymph node metastases. The results are comparable to Tc-99m-sestamibi and Tl-201 scintigraphy.

Serodiagnosis of recently acquired Toxoplasma gondii infection with a recombinant antigen

A portion of a cDNA encoding a 35-kDa antigen from Toxoplasma gondii was cloned into the CKS expression vector and expressed in Escherichia coli. By using the enzyme-linked immunosorbent assay (ELISA), the recombinant protein (rP35 antigen) was examined for reactivity with immunoglobulin G (IgG) antibodies in the sera of pregnant women. Of these women, 41 had a toxoplasma serologic profile suggestive of recently acquired T. gondii infection (Sabin-Feldman dye test [DT] titers from 1:256 to 1:32,000, positive IgM ELISA titers from 2.3 to 9.7, positive IgA ELISA from 1 to >28, and acute patterns in the differential agglutination [AC/HS] test) (group I), and 50 women had a toxoplasma serologic profile suggestive of infection acquired in the distant past (low DT titers from 1:16 to 1:512, negative IgM ELISA titers from 0 to 0.8, and chronic patterns in the AC/HS test) (group II). The classification of acute or chronic profile was based on the individual's clinical history as well as the combination of the results of the toxoplasma serological profile. An additional group (group III) was composed of sera from 50 women who were seronegative for T. gondii antibodies in the DT. The results revealed that whereas 85.3% of women in group I had IgG antibodies that reacted with the rP35 antigen, only 8% of women in group II had IgG antibodies that reacted with the same antigen. In immunoblots, the rP35 antigen was recognized by IgG antibodies in a pool of sera from individuals with a toxoplasma serologic profile compatible with acute infection but not in a pool of sera from individuals with a serologic profile characteristic of a chronic infection. These results reveal that IgG antibodies against the P35 antigen are produced during the acute stage of the infection but are uncommon in the latent or chronic phase of the infection. Thus, the rP35 antigen may be a useful serologic marker to differentiate between recently acquired infection and that acquired in the more distant past.

Detection of melanoma metastases with thallium-201 scintigraphy

Thallium-201 accumulates well in various malignant tumors. The aim of this study was to evaluate the potential of 201Tl imaging in patients with metastatic melanoma.

METHODS

Fifty patients with suspected melanoma metastases were studied after intravenous injection of a mean tracer activity of 100 MBq 201Tl-chloride. We took sequence images up to 5 min (15 sec/image) and immediate whole-body images with a double-headed camera and a high-resolution collimator.

RESULTS

Of 36 patients with metastatic melanoma confirmed by histopathology, metastases were detected in 28 patients using 201Tl imaging. The tumor-to-background ratio ranged from 2.0 to 4.5 (mean 3.2). There were 8 patients with false-negative findings (sensitivity = 78%). Five false-negative findings were lymph nodes greater than 1.5 cm with tumor-to-background ratios lower than 1.5. Only a few cutaneous metastases smaller than 1 cm could be detected. There was one false-positive finding of an inflamed lymph node. The optimum time for imaging was 2-5 min postinjection.

CONCLUSION

These data suggest that 201Tl imaging is an accurate method for the detection of melanoma metastases. The short waiting period after injection, the lack of side effects and the sensitivity of about 80% may qualify this method as a routine investigation in patients with high-risk melanoma.

The incidence of hyperthyroidism in Austria from 1987 to 1995 before and after an increase in salt iodization in 1990

Between 1963 and 1990, Austria had iodized salt prophylaxis of endemic goitre with 10 mg KI (7.5 mg I) per kg. This was obviously insufficient, as urinary iodine excretion ranged from 42 to 78 microg I per g of creatinine and goitre in adults remained in the endemic range of 15%-30%. Therefore salt iodization was doubled in 1990. The aim of this study was to assess the annual incidence of different types of hyperthyroidism (HT) before and after this increase in salt iodization. The incidence of HT was recorded in 14 nuclear medicine centres from 1987 to 1995. In five additional centres data were available from 1992 onwards. Data prior to 1992 were documented retrospectively, while those after 1992 were recorded prospectively. The 14 centres drew patients from an area with a population of approximately 4.23 million while all 19 institutes were estimated to cover an area with a population of 5.4 million (the total population of Austria is 7.86 million). A total of 414232 persons were examined for the first time in the participating centres. HT and the type of HT were defined by clinical examination, serum TSH, thyroid hormone levels in blood, ultrasonography, scintigraphy and serum autoantibody titres. HT was classified into immunogenic HT (Graves' or Basedow's disease, GD) and HT with intrinsic thyroid autonomy (uni-, multinodular or disseminated Plummers' disease, PD). HT was also divided into overt (o) or subclinical (sc) disease. The following data were calculated: annual incidence per 100000 and the relative risk (RR) for HT with 95% confidence intervals (CI). In addition, linear trends were calculated for each type of HT by means of logistic regressions. In the 19 centres a total of 47834 patients with HT were registered from 1987 to 1995. PD accounted for 75% of all cases of HT and GD for 19%, while other types of HT were present in 6%. From 1987 to 1989 (time period T0), the annual incidence of oPD was 30.5 (95% CI 29.6-31.5) per 100000. The RR compared to the baseline period T0 was highest in 1992 (1.37; 1.3-1.45) and decreased to 1.17 (1.1-1.24) in 1995. The annual incidence of scPD in T0 was 27.4 (26.5-28.3) per 100000. The RR was highest in 1991 (1.64; 1.56-1.73) and was 1.60 (1. 51-1.69) in 1995. In oPD and scPD a higher RR was observed in persons older than 50 years of age, particularly in men. The incidence of oGD in T0 was 10.4 (9.8-10.9) per 100000; the maximum RR increased to 2.19 (2.01-2.38) in 1993 and decreased to 1.95 (1.78-2.13) in 1995. The incidence of scGD was 1.9 (1.6-2.1) in T0. The maximum RR was observed in 1994 (2.47; 2.04-3.0) and it was still 2.26 (1.85-2.77) in 1995. The increased incidence of oGD and scGD was evenly distributed in all ages and both sexes. The time course of different types of HT following the increase in salt iodization could be divided into two phases: an increase in the incidences of HT with peaks after 1-4 years and a subsequent decrease, the only exception being scGD. The effect was more pronounced in GD than in PD. PD showed an age and gender dependency over time, while GD did not.

Luteinizing hormone-releasing hormone antagonist Cetrorelix (SB-75) and bombesin antagonist RC-3940-II inhibit the growth of androgen-independent PC-3 prostate cancer in nude mice

BACKGROUND

Hormones like bombesin (BN)/gastrin-releasing peptide (GRP) and luteinizing hormone-releasing hormone (LH-RH) and growth factors such as epidermal growth factor (EGF) might be involved in the relapse of prostate cancer under androgen ablation therapy. Interference with receptors for BN/GRP, LH-RH, or EGF might provide a therapeutic approach to inhibit tumor growth of androgen-independent prostate cancer.

METHODS

LH-RH antagonist Cetrorelix (SB-75) and the BN/GRP antagonist RC-3940-II were tested for their effects on the growth of the androgen-independent PC-3 human prostate cancer cell line xenografted into nude mice. Tumor growth, serum hormone levels, and receptor concentrations for BN/GRP and EGF were measured.

RESULTS

When the treatment was started, tumor volume in all groups was 70-80 mm3. After 4 weeks, tumor volume in the control animals injected with saline was 871 +/- 233 mm3 and that of animals treated with Cetrorelix only 197 +/- 61 mm3. The BN/GRP antagonist RC-3940-II also significantly reduced PC-3 tumor volume in nude mice to 122 +/- 20 mm3. The combination of Cetrorelix and RC-3940-II produced no additional inhibition. High-affinity receptors for EGF were detected in the tumor membranes and their number was significantly decreased after administration of Cetrorelix or RC-3940-II.

CONCLUSIONS

These findings demonstrate that LH-RH antagonists and BN/GRP antagonists inhibit the growth of the androgen-independent prostate cancer cell line PC-3 in vivo. Both analogs may exert a direct inhibitory effect on tumor growth through a down-regulation of EGF receptors.

Inhibition of growth of androgen-independent DU-145 prostate cancer in vivo by luteinising hormone-releasing hormone antagonist Cetrorelix and bombesin antagonists RC-3940-II and RC-3950-II

The aim of this study was to test the antagonist of LH-RH (Cetrorelix), agonist [D-Trp6]LH-RH (triptorelin) and new bombesin antagonists RC-3940-II and RC-3950-II for their effect on the growth of an androgen-independent prostate cancer cell line, DU-145, xenografted into nude mice. Xenografts were grown in male nude mice, and after 4 weeks, the animals were treated either with saline (control) or with one of the analogues. One group of mice was given a combination of Cetrorelix and RC-3950-II. Treatment was given for 4 weeks. Tumour and body weights, and tumour volumes were measured. At sacrifice, tumours were dissected for histological examination and receptor studies. Serum was collected for measurement of hormone levels. The final tumour volume in control animals injected with saline was 577 +/- 155 mm3 and that of animals treated with Cetrorelix only 121.4 +/- 45 mm3 (P < 0.01). Bombesin antagonists RC-3940-II and RC-3950-II also significantly reduced DU-145 tumour volume in nude mice to 84.9 +/- 19.9 and 96.8 +/- 28 mm3, respectively. Agonist [D-Trp6]LH-RH did not significantly inhibit tumour growth. Serum levels of LH were decreased to 0.08 +/- 0.02 ng/ml (P < 0.05) in the Cetrorelix treated group as compared to 1.02 +/- 0.1 ng/ml for the controls, and testosterone levels were reduced to castration levels (0.01 +/- 0.01 ng/ml). Specific receptors for EGF and LH-RH in DU-145 tumours were significantly downregulated after treatment with Cetrorelix, RC-3940-II and RC-3950-II. Although LH-RH could be a local regulator of growth of prostate cancer, the fall in LH-RH receptors is not fully understood and the inhibitory effects of Cetrorelix and bombesin antagonists on DU-145 tumour growth might be attributed at least in part to a downregulation of EHF receptors. Since Cetrorelix and bombesin antagonists inhibit growth of androgen-independent DU-145 prostate cancers, these compounds could be considered for the therapy of advanced prostate cancer in men, especially after relapse.

[Selective regional lymphadenectomy in malignant melanoma using a gamma probe]

The accurate excision of the first tumour draining lymph node (sentinel lymph node SLN) can prevent extended surgery intervention in many patients with malignant melanoma. The aim of our study was to test the practicability of the SLN dissection using a gamma probe. In a total of 52 patients, mostly with high-risk melanoma, a selective lymph node dissection was performed. We injected intracutuneously about 50 MBq Tc-99m colloid around the tumour or scar followed by dynamic and late static imaging. The site of SLN was localized with a gamma probe and marked on the skin. This was followed by the dissection of the SLN using the gamma probe. In 51 of 52 patients the SLN could be found intraoperatively using the gamma probe. The SLN contained microscopic metastases in 13 patients (24%). The rate of positive SLN was 40% in patients with high-risk melanoma (Breslow thickness more than 1.5 mm). In case of positive SLN a second surgical intervention with radical lymph node dissection was followed. We conclude that dynamic lymphscintigraphy and the selective lymph node dissection using the gamma probe is a simple and minimally invasive method which can improve the survival probability in patients with micrometastases.

[Anaphylactic shock after repeated injection of 99mTc-labeled CEA antibody]

In a 64-year old patient with a recurrent rectal carcinoma, immunoscintigraphies with 99mTc-labelled monoclonal antibody against CEA (BW 431/26) were performed in an interval of 14 months. A few minutes after the second injection the patient reacted with anaphylactic shock which could be controlled by epinephrine and cortisone. As far as we know, there is no report in the literature on an anaphylactic reaction to this antibody. An investigation for human anti-mouse antibodies before the second injection was negative with one method and positive with another method.

Mediastinal tumor and Klinefelter's syndrome

Klinefelter's syndrome with karyotype 47,XXY in patients with primary extragonadal germ cell tumors rarely occurs. The endocrinology of Klinefelter's syndrome is changed; elevated beta-human choriomic gonadotropin levels are present. Chemotherapy and thoracic surgery brought complete remission in a patient with lung metastases.

99mTc-DTPA aerosol for same-day post-perfusion ventilation imaging: results of a multicentre study

A multicentre study was performed in an attempt to evaluate a submicronic technetium-99m diethylene triamine penta-acetic acid aerosol generated by a newly developed delivery system, the aerosol production equipment (APE nebulizer), for same-day post-perfusion ventilation imaging in patients with clinically suspected pulmonary embolism. Quantitative comparison between the DTPA aerosol and krypton gas demonstrated a close correlation with respect to regional pulmonary distribution of activity and peripheral lung penetration (n = 14, r = 0.94, P < 0.001 and r = 0.75, P < 0.0025, respectively). In 169 consecutive patients, DTPA aerosol images performed immediately following perfusion (inhalation scan I) were compared to those carried out on the next day (inhalation scan II) with respect to image quality and assessment of perfusion-ventilation matches or mismatches. Agreement between inhalation scans I and II with respect to perfusion defects matched or mismatched to ventilation was found in 166/169 (98%) studies. The image quality of inhalation scan I was equal to that of scan II in 72%; inhalation scan I was superior in 11% of cases, while scan II was superior in 17%. This submicronic 99mTc-labelled DTPA aerosol is well suited for fast same-day post-perfusion ventilation imaging in patients with clinical suspicion of pulmonary embolism.

[Value of preoperative fine needle puncture cytology in the diagnosis of highly malignant thyroid tumors]

Highly malignant thyroid tumours are frequently diagnosed only at an advanced stage where radical resection is no longer feasible. By the wide application of fine needle aspiration biopsy as a diagnostic tool in nodular thyroid diseases occasionally early stages of these tumours can be diagnosed. Despite early detection in 23% of our patients with anaplastic carcinomas and sarcomas of the thyroid gland and subsequent radical resection an improvement in the long-term outcome was not achieved. In contrast, thyroidectomy and appropriate oncologial therapy may result in long-term survival of patients with early stages of thyroid lymphomas.

Hyperthyroidism and concurrent thyroid malignancies

In a 17-year period 1848 patients with hyperthyroidism were operated on. Fourteen (0.76%) had a coexisting thyroid malignancy. Preoperative scintiscan and pathologic diagnoses were compared: 10 malignancies were in cold nodules, two were unidentifiable preoperatively due to small size, and two were in hot areas. Five patients had papillary cancer, four follicular, three anaplastic, and two medullary. Patients with uninodular toxic goiter had a low rate of associated malignancy (0.27%, 3/1108). In contrast, patients with multinodular toxic goiter had an incidence of 1.63% (11/676). No patient with Graves' disease (n = 64) had a carcinoma. Extensive use of fine-needle aspiration biopsy enabled preoperative diagnosis in a majority of the cases (9/14, 64%). We conclude that the incidence of coexisting thyroid malignancy and hyperthyroidism is rare in our endemic iodine-deficiency goiter area.

Pulsatile luteinizing hormone-releasing hormone treatment of male hypogonadotropic hypogonadism

Luteinizing hormone-releasing hormone (LH-RH) secretion from the hypothalamus follows a rhythmic pattern, inducing pulsatile luteinizing hormone (LH) and follicle-stimulating hormone (FSH) secretion from the pituitary gland. Consideration of this physiologic principle led to the introduction of pulsatile LH-RH therapy via infusion pump for the treatment of different forms of hypogonadotropic hypogonadism. We report on 10 male patients, 16 to 28 years of age, suffering from idiopathic hypogonadotropic hypogonadism (IHH) including Kallman's syndrome (n = 2) and delayed puberty (n = 2). All presented with complete eunuchoidism and had undergone no treatment for their conditions during the previous 2 years. LH-RH was administered in subcutaneous pulses of 4 to 16 micrograms, with a portable infusion pump (ZYKLOMAT, Ferring Corp., Kiel, FRG); treatment periods ranged from 6 to 24 months. With therapy, the subjects improved secretion of LH, FSH and testosterone. Testicular volumes and penis size increased; all patients developed normal secondary sexual characteristics. Spermatogenesis was induced in all patients. The time to onset of spermatogenesis ranged from 3 to 15 months. No major side effects were observed, and no patient dropped out of the study. The results indicate that pulsatile LH-RH therapy is an highly effective treatment for IHH and delayed puberty.

Effects of high and low doses of methimazole in patients with Graves' thyrotoxicosis

In spite of the long-established use of antithyroid drugs, there are many unsettled questions connected with this treatment of Graves' disease. There is a lack of controlled prospective trials studying the results of antithyroid drug therapy while considering the many variables such as disease heterogeneity, regional differences, drug dosage and duration of treatment. Therefore, a multicenter study has been set up in order to compare the effects of two fixed doses of methimazole (10 vs 40 mg) with thyroid hormone supplementation on the clinical, biochemical and immunological course of Graves' disease and on remission rates. Experience accumulated so far suggests that treatment is safe using either 10 or 40 mg of methimazole. While there is a tendency for an advantage of the higher dose within the first weeks (higher effectiveness in controlling hyperthyroidism), this difference is not significant. The impact of dosage on remission rates remains to be shown.

[Should the iodination of table salt be increased in Austria?]

Since the main reason of endemic goiter is the avoidable iodine deficiency, this in an unnecessary disease. In Austria an exemplary iodized salt prophylaxis was introduced in 1963. Thanks to this iodized salt prophylaxis endemic cretinism has died out. The incidence of hypothyroidism in newborns is currently 1 : 4600, goiter frequency in the first school year now only 1.1 to 1.5%. In contrast the goiter incidence in girls in the twelfth school year increases to 13.4% and up to one third of adults are afflicted by goiter. Studies of iodine excretion in Feldkirch, Innsbruck, Salzburg, Graz and Vienna on a total of 2627 patients showed an iodine excretion of less than 100 micrograms J/g creatinine in the majority of the patients. This proves that there is still an inadequate iodine supplement. The Austrian Nuclear Medicine Society therefore recommends an increase in the potassium iodide content from the present 10 mg potassium iodide/kg to 20 mg potassium iodide/kg table salt, in keeping with the procedure introduced in Switzerland in 1980. Through this measure a decrease in the goiter frequency to less than 3% is to be expected over a longer period. This will result in a considerable reduction in the costs of diagnosis and therapy for this disease. There might be a temporary increase in hyperthyroidism for a certain period as a result of the increase of the content of iodide in the table salt.

[Complete regeneration of the right liver after hemihepatectomy]

Right hemi-hepatectomy was performed in two patients because of metastases in one and a malignant hepatoma in the other. After five and six months, respectively, a right hepatic lobe was again demonstrated, at first by ultrasound, then by isotope scanning. Further studies by coeliacography, 99Tc hepatobida, CT scan and liver-biopsy histology from the regenerated lobe revealed a functionally and morphologically normal picture of a right hepatic lobe, the external form of the regenerated right lobe being identical with the original one. A histologically and functionally unchanged residual liver is considered the prerequisite for satisfactory regeneration after resection. Liver regeneration, as far as regulating factors are concerned, seems to be under similar hormonal control mechanism as external wound healing.

[Iodine deficiency in Salzburg in spite of iodized table salt prophylaxis]

Urinary iodine excretion was determined in 293 medical technical and nursing students in hospitals of the province Salzburg. The average urinary iodine excretion amounted to 46.6 +/- 18 micrograms iodine per gram creatinine. 67.6% of the students showed a deficiency of iodine II, whilst 98.3% had a deficiency of iodine I according to WHO criteria. Urinary iodine levels and natriuria are closely correlated, indicating that iodized table salt probably constitutes the most important source of iodine. 73 of the students had a palpable giotre, 10 of these being nodular. Our investigations, together with those of Innsbruck, Graz and Vienna, demonstrate the existence of generalized iodine deficiency in spite of iodized salt prophylaxis, which has been legally enforced in all of Austria since 1963. Iodized table salt prophylaxis has, thus, led to a drastic decrease in goitres in children, but is not sufficient to eliminate iodine deficiency in adults. An increased level of iodization of table salt, as has been put into force in Switzerland, must be called for in Austria, too.

[Therapy of thyroid cysts with fine needle aspiration]

In a study extending over a period of 4 years, therapeutic fine-needle aspirations were carried out in 194 thyroid patients with thyroid cysts. The cyst contents of 3-130 ml cyst fluid were completely removed by suction in 2-3 month intervals by 1-17 fine-needle aspirations on an outpatient basis. Malignancy was ruled out in all patients by repeated cytological tests. Complete emptying of the cyst, verified by twice-repeated check at 3-month intervals, was achieved in 86 patients (44.3%). A reduction of the cyst fluid to less than 30% was achieved in 13 patients (6.7%). In 17 patients (8.8%) the cyst fluid diminished to 31-50%. In 44 patients (22.7%) there was no diminution in the cyst fluid or a reduction of less than 50%. There was an increase in cyst fluid compared with the first puncture in 34 patients (17.5%). The success of puncture cannot be predicted, although cysts with brown cyst fluids can be emptied significantly more frequently than cysts with yellow cyst fluids (63% as compared with 43.5%, p less than 0.005). Cyst fluid volume, T3- and T4-contents of the cyst fluid, age and sex had no influence on therapeutic effect. Up to the 5th puncture the prospects of success are approximately constant, but even in cases of more frequent punctures emptying still takes place. Thyroid hormone therapy with 50-100 micrograms 1-T4 daily (n = 134), and a single intracystic injection of 40 mg methylprednisolone-crystal suspension (n = 42) or of 0.02 g hydroxypolyaethoxydodecan 1% (n = 11) did not show better results than the single aspiration. There were no complications except for 2 cases of afterbleeding in the cysts immediately after puncture, and these were easily dealt with. Fine-needle aspiration is a simple, effective and cost-saving method for the elimination of the frequent cosmetically disturbing thyroid cysts in half of patients, thus avoiding surgery.