The PRIMARA study: a prospective, descriptive, observational study to review cinacalcet use in patients with primary hyperparathyroidism in clinical practice

OBJECTIVE

Medical management of primary hyperparathyroidism (PHPT) is important in patients for whom surgery is inappropriate. We aimed to describe clinical profiles of adults with PHPT receiving cinacalcet.

DESIGN

A descriptive, prospective, observational study in hospital and specialist care centres.

METHODS

For patients with PHPT, aged 23-92 years, starting cinacalcet treatment for the first time, information was collected on dosing pattern, biochemistry and adverse drug reactions (ADRs). Initial cinacalcet dosage and subsequent dose changes were at the investigator's discretion.

RESULTS

Of 303 evaluable patients with PHPT, 134 (44%) had symptoms at diagnosis (mostly bone pain (58) or renal stones (50)). Mean albumin-corrected serum calcium (ACSC) at baseline was 11.4 mg/dl (2.9 mmol/l). The reasons for prescribing cinacalcet included: surgery deemed inappropriate (35%), patient declined surgery (28%) and surgery failed or contraindicated (22%). Mean cinacalcet dose was 43.9 mg/day (s.d., 15.8) at treatment start and 51.3 mg/day (31.8) at month 12; 219 (72%) patients completed 12 months treatment. The main reason for cinacalcet discontinuation was parathyroidectomy (40; 13%). At 3, 6 and 12 months from the start of treatment, 63, 69 and 71% of patients, respectively, had an ACSC of ≤10.3 mg/dl vs 9.9% at baseline. Reductions from baseline in ACSC of ≥1 mg/dl were seen in 56, 63 and 60% of patients respectively. ADRs were reported in 81 patients (27%), most commonly nausea. A total of 7.6% of patients discontinued cinacalcet due to ADRs.

CONCLUSIONS

Reductions in calcium levels of ≥1 mg/dl was observed in 60% of patients 12 months after initiation of cinacalcet, without notable safety concerns.

[Recommendation of the Czech Society of Endocrinology for the treatment of Cushing's syndrome in adults]

Cushing's syndrome is a rare disorder with variable aetiology which is connected with significantly increased morbidity and mortality. Therefore, early determination of correct aetiology and early treatment are essential for a decrease of morbidity and mortality of patients. Present article introduces review and current recommendation of Czech Society of Endocrinology for the treatment of Cushings syndrome.

[Androgen deficit and diabetes]

Low testosterone level is common in obese men and even more frequent in the presence of type 2 diabetes mellitus. Low testosterone level is probably not caused by increased aromatization of testosterone to estradiol in fat tissue. Increase of inflammation mediators, insulin and leptin resistance and low SHBG level may play more important role. Low testosterone level may manifest with low libido, erectile dysfunction, fatigue and depressive mood; it has a role in development of anaemia, osteoporosis, worsening of insulin resistance and it is probably marker of increased all-case and cardiovascular mortality. Routine investigation of testosterone level is indicated in every man with type 2 diabetes mellitus. As in non-diabetic men of middle and higher age substitution is indicated only in presence of clinical symptoms of hypogonadism. The substitution improves mainly libido, erectile dysfunction is influenced less. However, the phosphodiasterase-5 inhibitors efficiency is markedly improved. Metabolic changes during testosterone substitution are small.

[Incretin hormones]

Incretin hormones are peptides that are secreted from endocrine cell of gastrointestinal tract after nutrient ingestion and stimulate insulin secretion. Glucosodependent Insulinotropic Peptide--GIP is released from K-cells of duodenum and proximal jejunum, recently GIP synthesis has been proved in pancreatic alpha cells. Besides the incretin effect causes GIP increased lipogenesis and decreased lipolysis in fat tissue, increased bone formation and decreased resorption and has protective and proliferative effect on CNS neurons. Both GIP agonists (to treat diabetes) and antagonist (to treat obesity) are being studied. Another incretin hormone is derived in intestinal I-cells by posttranslational processing of proglucagon--glucagon-like peptides 1 and 2 (GLP-1 and GLP-2). GLP-1 stimulates insuline production and inhibits glucagon secretion, exerts proliferative and antiapoptotic effect on beta-cells. Via receptors on vagal nerve and central mechanisms decreases food intake and decreases body weight. By deceleration of gastric emptying it attenuates increases in meal-associated blood glucose levels. It exerts cardioprotective effects. GLP-1 receptors have been proved in liver recently but decreased liver glucose production and increased glucose uptake by liver and muscle are mediated indirectly by altering insulin and glucagons levels. GLP-2 stimulates enterocytes proliferation, up-regulates intestinal nutrient transport, improves intestinal barrier function, and inhibits gastric and intestinal motility. GLP-2 also reduces bone resorption.

[Endocrine abnormalities and vessels in patients with diabetes]

Endocrine impairment is more common in patients with diabetes than in general population. Both hyper- and hypothyroidism increases cardiovascular morbidity and mortality. Subclinical hypothyroidism is a risk factor for coronary hearth disease in patients younger than 65 years. In elderly is its influence questionable or even preventive and the benefit of substitution should be weighted against the risks. Treatment with glucocorticoids in a dose of 7.5 mg methylprednisolone and higher considerably increases risk of vascular impairment. Patients cured from endogenous Cushing's syndrome maintain increased cardiovascular risk factors and structural changes of vessels. Subclinical hypercortisolism seems to have little effect. Growth hormone (GH) insufficiency increases cardiovascular risks and contributes to increased mortality of these patients. To the contrary increased GH production in acromegaly effect more heart than vessels. Hypogonadism is established risk factor for ischemic accidents in men. The relationship between hypogonadism and diabetes is bidirectional. Low testosterone level increases the risk of type-2 diabetes and in diabetics is the testosterone level often low. Substitution with testosterone can not only ameliorate hypogonadal symptoms but also decrease cardiovascular risk and even improve control of diabetes.

[Experimental small intestine transplantation]

AIM

Transplantation of the small intestine is a standard treatment method in patients with small intestinal failures. The aim of this study was to master the surgical technique, optimalize immunosuppression regimes, diagnose acute cellular graft rejection based on cellular and humoral indicators.

METHODS

The authors performed a total of 43 transplantation procedures in pigs. The first, surgical part of the experiment was aimed at mastering two principal methods of vascular anastomosis- firstly, connecting the graft with mesenteric vessels (Group n1 = 18) and secondly, connecting the graft with the aorta and the inferior vena cava (Group n2 = 25). The second part of the experiment included assessment of rejection changes in various immunosuppression regimes. Only animals who did not die because of a technical failure of the procedure or due to internal reasons (n = 24) were assessed. The study animals were assigned to four groups (A (n = 3)--autotransplantation, without immunosuppresion; B (n = 7) and C (n = 8)--allotransplantation with immunosuppression using tacrolimus, resp. in a combination with sirolimus; D (n = 6)--allotransplantation without immunosuppression. Rejection was diagnosed based on histological examination of the grafts@ biopsy samples. Plasmatic citruline was used as a non-invasive humoral indicator of the graft impairment.

RESULTS

Procedural complications were observed in 12 (67%) study animals from the first group, and in 3 (12%) animals from the second group. In the assessment of rejection changes, the longest survival was observed with autotransplantations, the shortest survival period was shown with allotransplantations without immunosuppression. No significant survival differences were demonstrated between the both treated groups. (p < 0.05). Group C showed lower rates of cellular rejections, compared to Group B and D.

CONCLUSION

During the experiment, the authors managed to master the graft collection, as well as the transplantation technique. Lower rates of surgical complications were observed when the graft was supplied by the central vascular system. No significant differencies were observed between the tacrolimus monoterapy regimen and the combination therapy with sirolimus. Histological examination is the golden standard for the cellular rejection diagnostics. Plasmatic citruline has no signifiance in the rejection assessment.

[Hypothyroidism substitution and adrenal insufficiency in diabetic patients]

As diabetes mellitus type 1 is part of the polyglandular autoimmune syndrome it is no wonder that autoimmune disorders of the thyroid are in diabetics about five times more common and adrenal insufficiency four times more common than in general population. Manifest hypothyroidism leads to the decrease in insulin sensitivity and increase of glucose stimulated insulin secretion. These changes are reversible by substitution. Even subclinical hypothyroidism increases demand on pancreatic beta cell. The glucocorticoid insufficiency causes marked increase of insulin sensitivity, decrease of endogenous glucose production and increase of glucose oxidation. Synthetic thyroxin is optimal for thyroid hormones substitution. Combined substitution with trijodthyronin did not proved to have any beneficial effect. The basis of substitution in adrenal insufficiency is replacement of hydrocortisone in doses that do not have negative metabolic effects. Preparations available today do not allow imitating the nature diurnal rhythm but slow-release tablets are being tested. Androgen substitution is not routinely recommended.

Expression of galectin-3, cytokeratin 19, neural cell adhesion molecule and E-cadhedrin in certain variants of papillary thyroid carcinoma

The immunohistochemical expression of galectin-3 (Gal3), cytokeratin 19 (CK19), neural cell adhesion molecule (NCAM), and E-cadherin (Ecad) was evaluated to assess their use in diagnostics of papillary thyroid carcinoma (PTC). A total of 84 PTCs - 36 classical variants (cPTCs), 26 follicular variants (fPTCs), and 22 papillary microcarcinomas (mPTCs) were studied. Expression of Gal3 was found in 36/36 (100%) cPTCs, 24/26 (92%) fPTCs, and 19/22 (86%) mPTCs. CK19 expression was detected in 34/36 (94%) cPTCs, 17/26 (65%) fPTCs, and 13/22 (59%) mPTCs. Expression of NCAM was seen in 5/36 (14%) cPTCs, 7/26 (27%) fPTCs, and 9/22 (41%) mPTCs. Ecad expression was found in 23/36 (64%) cPTCs, 17/26 (65%) fPTCs, and 18/22 (82%) mPTCs. A significant difference in CK19 expression was observed between cPTC and both fPTC and mPTC (p < 0.001). Furthermore, extrathyroid tumor spread significantly correlated with both level of CK19 expression and loss of Ecad expression (p = 0.001, p = 0.04). Our findings suggest that Gal3 and CK19 are useful markers for PTC, although decreased CK19 expression in mPTC and fPTC must be considered. Furthermore, CK19 and Ecad may play a role in extrathyroid tumor spread.

[Pendred syndrome among patients with hypothyroidism: genetic diagnosis, phenotypic variability and occurrence of phenocopies]

BACKGROUND

Pendred syndrome (OMIM274600) is one of the causes of congenital hypothyroidism due to thyroid dyshormonogenesis. It is an autosomal recessive disease classically characterized by dyshormonogenetic goitre and sensorineural deafness. It is caused by mutations in PDS/SLC26A4 gene encoding for pendrin--an anion transporter, mostly expressed in the thyroid gland and the inner ear. The thyroid impairment in Pendred syndrome develops only in 80% of affected individuals in form of a euthyroid or hypothyroid goitre, which is rarely present at birth, when it can be diagnosed by the neonatal screening for congenital hypothyroidism. The study was aimed to identify patients with Pendred syndrome among children with congenital or postnatal non-autoimmune hypothyroidism and subsequently confirm the diagnosis by finding mutations in the PDS/SLC26A4 gene.

METHODS AND RESULTS

We examined two-hundred thirty-six Caucasians with hypothyroidism diagnosed by screening or developing later in childhood. The clinical diagnosis of Pendred syndrome was based on the laboratory and ultrasonographic signs of thyroid dyshormonogenesis (elevated TSH, low T4/fT4, goitre or normal thyroid volume) in association with sensorineural hearing loss. In subjects clinically diagnosed as Pendred syndrome, we sequenced all 21 exons of the PDS/SLC26A4 gene and their flanking intron-exon junctions. Among 236 children, nine fulfilled the diagnostic criteria of Pendred syndrome. In four, the diagnosis was confirmed by identification of mutations in the PDS/SLC26A4 gene, the remaining five patients were concluded phenocopies.

CONCLUSIONS

Our study confirms the high phenotypic variability of thyroid impairment in Pendred syndrome and underlines the necessity of a molecular-genetic investigation for establishing the diagnosis in regard of the great number of phenocopies. However, from the endocrinologist's point of view, the genetic testing is only reasonable in patients with congenital hypothyroidism due to dyshormonogenesis in association with sever to profound sensorineural hearing loss.

[Aspiration cytology of the thyroid]

Fine needle aspiration cytology is a basic type of examination in thyreology today. It is primarily indicated for thyroid node to exclude a malignant tumour. The presence of multiple nodes or of one node only has shown to be indicative of the same amount of risk of a malignant tumour for the patient. Ultrasound characteristics are insufficient for the determination of the nature of the focus and all the existing nodes greater than 10 mm are an indication for puncture. As for other diseases, aspiration cytology is indicated in granulomatose thyreoiditis, while in Hashimoto thyreoiditis it is usually indicated only if a node is present. In addition to clearly benignant and clearly malignant results, large part of cytological conclusions fall within the category of suspicious (unclear) findings. All of them are an indication for histological verification, and the predictive value of the results depends on their type. It is approximately 20% in the case of follicular neoplasia, and preoperative histology is useless. Therefore we mostly opt for hemithyreoidectomy, further procedure depending on the final histological finding.

[Thyroid orbitopathy and diabetes]

Thyroid-associated ophthalmopathy (TAO) is an inflammatory process associated with autoimmune thyroid diseases (AITD), most commonly Graves disease. It is clinically present in up to one half of patients suffering with AITD and 3-5 % of patients suffer from intense pain and inflammation with double vision or even loss of vision. Because diabetes mellitus type 1 and AITD have similar pathogenesis and shared genetic background it is not surprising that up to 30% of patients with type 1 diabetes develop AITD during long term follow-up. It is important to consider the activity and severity ofTAO separately. Treatment is effective at the beginning of disease in the high activity phase. Glucocorticoids represent a milestone in the treatment of TAO and are necessary in diabetic patients as well. According to the latest experience the most effective and best tolerated regimen is iv glucocorticoid administration of methylprednisolone at weekly intervals up to a cumulative dose of 4.5 g. Orbital radiotherapy is considered to be contraindicated in patients with diabetes for fear of worsening retinopathy. Surgical orbital decompression is indicated in severe proptosis and progressive neuropathy in the acute stage. Rehabilitative (extraocular muscle or eyelid) surgery is often needed after treatment and inactivation of eye disease.

[Hormonal diseases after traumatic brain injury]

Traumatic brain injury represents major medical and social problem in all developed countries. Its incidence is about 200 per 100,000 inhabitants per year. In the acute phase immediately after injury the posterior pituitary dysfunction is well-known. The incidence of severe grossly hypernatremic cases of diabetes insipidus (DI) is about 3%, less severe form of ADH insufficiency was recognized in 21-26%. The syndrome of inappropriate antidiuretic hormone secretion (SIADH) was described in about 14%. These changes are transient in most cases, persisting DI has an incidence of 5-7% and SIADH cases recover almost always. Since the beginning of this century several series evaluating prospectively all patients after moderate to severe TBI have been published. Permanent hypopituitarism was found in one quarter to one half of them. The most common turned out to be the growth hormone (17.6%) and gonadotropic (13.4%) deficiency. Less common is the corticotropic (8.4%) and thyrotropic (4.3%) insufficiency. In the majority of patients an isolated dysfunction was discovered. However, in 9%, a combined failure of two or more HPA axis was present. This paper describes the minimum investigation needed to diagnose hypopituitarism by patients after TBI, who may profit from substitution therapy.

[Possibilities of medical treatment in acromegaly]

Active acromegaly deteriorates the quality of life and shortens the life expectancy. Surgery is the first-line therapy in the majority of patients, followed by radiotherapy in unsuccessful cases. The surgery cure rate is only one half in the case of macroadenomas and it takes years before radiotherapy normalizes GH and IGF-I levels. In the interim, medical therapy is necessary. Second-generation dopamine agonists (cabergoline) are successful in about one third of patients, especially in those with lower basal IGF-I levels and with adenomas co-secreting prolactin. Somatostatin analogues octreotide and lanreotide are the gold standard of medical treatment - both are available in a form applicable as once-monthly injections. They successfully control disease activity in the majority of patients and induce tumour shrinkage in part of adenomas. Surgical debunking of macroadenomas improves the results of therapy with somatostatin analogues and it is not necessary to discontinue this therapy before radiotherapy. The potential of higher efficiency represent new analogues, binding not only to somatostatin receptor subtype 2, but also to subtype 5 and "dopastatins" that are able to bind both to the somatostatin and the dopamine D2 receptors. The advent of the GH receptor antagonist pegvisomant provides the possibility to normalise IGF-I in virtually every patient. Combined treatment with somatostatin analogues probably enables reduction from daily to weekly injections.

[Spontaneous necrosis of parathyroid adenoma]

The authors describe a female patient with large parathyroid gland adenoma presenting with clinical symptoms of primary hyperparathyroidism and severe hypercalcaemia. Before planned surgical treatment the patient spontaneously developed clinical symptoms of tetany. Hypocalcaemia was confirmed by laboratory test. The reason turned out to be spontaneous necrosis of the parathyroid adenoma, resulting in remission of hyperparathyroidism. After stabilization of calcium levels, the necrotic adenoma was removed and histopathological examination revealed necrotic adenoma with only occasional vital adenoma cells. During the next follow-up the patient was without any subjective complaints and her state was stable. This phenomenon, yet described in the literature in past, belongs to unusual findings.

[Thyroid peroxidase in the differential diagnosis of thyroid gland lesions. A marker of biological behavior or differentiation?]

Human thyroid peroxidase (hTPO) is a membrane protein with a key role in the thyroid hormones synthesis. Loss of hTPO was described in malignant tumours of the thyroid gland. hTPO was tested as a marker of malignancy. Immunohistochemical study of hTPO in 321 thyroid lesions (45 malignant tumours, 72 benign tumours, 199 benign non-tumours lesions, and 5 normal thyroid glands) is presented. The sensitivity of hTPO in predicting malignancy in thyroid is 64%, and the specificity is 87%. Thus, hTPO is of limited value in the diagnosis of thyroid malignancy. The authors discuss the role of hTPO as a marker of differentiation.

[Dipeptidyl peptidase IV (DPP IV, CD 26): a tumor marker in cytologic and histopathologic diagnosis of lesions of the thyroid gland]

BACKGROUND

Morphological diagnostics of thyroid gland tumours faces certain differential diagnostic problems. Extensive histological examination of the entire tumour is required for the final diagnosis of follicular and oncocytic tumours. Thus, assessment of reliable definitive cytological and/or intraoperative histological diagnosis is not possible. No marker of malignancy has been so far generally accepted in the thyroid tumour diagnosis. The aim of the study was to evaluate membrane protease dipeptidyl peptidase IV (DPP IV) in the differential diagnosis of thyroid tumours.

METHODS AND RESULTS

DPP IV was assessed cytochemically in 254 smears, histochemically in 314 cryostat sections, and immunohistochemically in 309 paraffin-embedded sections obtained from the group of 336 patients. There were 283 females and 53 males with the mean age of 48 years (range 15-80 years) in this series. Sensitivity of cytochemical detection was 71%, specificity was 96%, and diagnostic accuracy was 93% using the 50% threshold. Histochemically, sensitivity was 71%, specificity was 93%, and diagnostic accuracy was 90% using the 5% threshold. Using the immunohistochemical assessment, sensitivity was 68%, specificity was 94%, and diagnostic accuracy was 91% using the 5% threshold.

CONCLUSIONS

According to our results, DPP IV can be used as a marker of malignancy in well-differentiated carcinomas of follicular cell origin, namely in papillary carcinoma. However, it is less reliable in follicular and oncocytic carcinomas.

Diagnostic role of markers dipeptidyl peptidase IV and thyroid peroxidase in thyroid tumors

BACKGROUND

In seeking to improve the differential diagnosis between malignant and benign thyroid tumors of follicular cell origin, we assessed the expression of dipeptidyl peptidase IV (DPP IV) and thyroid peroxidase (TPO). DPP IV is a membrane peptidase expressed in many human tissues, excluding the normal thyroid gland. However, aberrant expression has been described in thyroid carcinomas. TPO is an essential enzyme in the biosynthesis of thyroid hormones with various types of expression in pathological thyroid lesions.

MATERIALS AND METHODS

A total of 151 thyroid glands were examined: 24 malignant tumors, 29 benign tumors, 98 benign lesions and 5 normal glands. DPP IV expression was analyzed by a histochemical technique in both frozen sections and imprint/aspirate smears. TPO was assessed immunohistochemically in paraffin-embedded specimens.

RESULTS

DPP IV sensitivity in frozen section was 56% and its specificity was 99%, in both cases with a 50% threshold. In cytology, the sensitivity was 68% and the specificity was 98% using the 50% threshold. TPO sensitivity and specificity was 64% and 99%, respectively. The sensitivity and specificity of both markers was 92% and 94%, respectively.

CONCLUSION

We recommend adding DPP IV and TPO to the list of diagnostic tumor markers for malignant thyroid tumors of follicular cell origin.

Dipeptidyl peptidase IV expression in thyroid cytology: retrospective histologically confirmed study

Fine needle aspiration cytology (FNAC) of the thyroid gland is a well-established method. However, it has inherent limitations, especially in the diagnosis of follicular and oncocytic tumours and in distinguishing between nuclear atypia in colloid goitre with regressive changes and cystic papillary carcinoma. The aim of our study was to evaluate dipeptidyl peptidase IV (DPP IV) as a marker of malignancy in FNAC. We tested 254 thyroid specimens (intraoperative imprint smears) for DPP IV. The sensitivity was 71%, the specificity was 96%, and the diagnostic accuracy was 93%, respectively, with a threshold of 50% of positive cells. To the best of our knowledge it is the largest histologically confirmed study reported in the literature. We suggest the assessment of DPP IV as an adjunct diagnostic marker of malignancy in thyroid specimens suspicious of papillary carcinoma. However, the value of the marker in follicular lesions is very limited.

[Epithelioid hemangiosarcoma of the thyroid gland]

Authors present a case of epithelioid haemangiosarcoma of the thyroid gland in a 54-year-old female with a history of eufunctional nodular goitre. The patient was treated by total thyroidectomy with extirpation of cervical lymph nodes and by subsequent chemotherapy. The tumour behaved highly aggressively with early generalization and unusual way of metastatic spread into the wall of the stomach and duodenum. The patient died 3 months after the surgery due to therapeutically unmanageable bleeding into the GIT. The clinico-pathological aspects of the case are discussed.

[Secondary changes in the thyroid gland induced by aspiration cytology]

Due to the introduction of fine needle aspiration cytology (FNAC) to the routine clinical preoperative examination surgical pathologists are faced with thyroid gland specimens with FNAC-induced secondary changes. These changes can cause diagnostic difficulties and be a source of incorrect diagnosis. Authors present a review of FNAC-induced changes with differential diagnostic criteria helpful in these pitfalls. FNAC-induced changes can be schematically divided into two major groups--recent ones (intranodal bleeding and/or necrosis) and subacute/late ones (proliferation of granulation tissue with predominance of myofibroblasts or endothelial cells, resorptive pseudoxantomathous granulomas, formation of sarcoid-like granulomas, capsular pseudoinvasion and scarring). Pathologists should be informed about the previously performed FNAC and must be aware of these lesions to prevent their misinterpretation.

[Dipeptidyl(amino)peptidase IV in the differential diagnosis of thyroid gland tumors: methods and results of a pilot study of 200 cases]

The use of dipeptidyl aminopeptidase IV (DPP IV) staining by azo-coupling in preoperative and intraoperative diagnostics of thyroid lesions is presented. In a series of 200 histologically confirmed cases examined, the sensitivity and the specificity were 71% and 99%, respectively in 124 smears, and 70% and 94%, respectively in 189 frozen sections. DPP IV expression showed high negative predictive value as well. DPP IV is suggested as an additional tool in the preoperative and intraoperative diagnostics of thyroid lesions.

Correlation of clinical picture (event free survival and overall survival) in childhood acute leukemia patients with immunophenotype and chromosomal abnormalities

In a group of 102 children with different immunological subtypes of acute leukemia, both lymphoblastic and nonlymphoblastic, the clinical parameters - event free survival and overall survival were correlated with numerical and structural chromosomal abnormalities. In a group of 80 ALL patients genetic abnormalities were observed in 40 patients, from those 19 of numerical type, 17 of structural type and 4 with both, numerical and structural anomalies. From the whole ALL group observed 23 patients (28.75%) died. In 10 died patients genetic abnormalities were found and in 6 cases less mature T-phenotype ALL has been documented. It seems, therefore, that immature T-phenotype with pathological karyotypes of all types of genetic anomalies presents the most risk group of patients of which all children died. ALL patients, as a whole, with pathological karyotype have shown significantly lower event free survival rate, comparing to the group of ALL patients with normal karyotype. Overall survival rate was also lower in the first group, but statistically not significant. In T-ALL patients, in both groups, with and without pathological karyotype, event free survival rate and overall survival rate were also lower in the first group, but statistically not significant. In B-ALL patients with pathological karyotypes vs. normal ones overall survival rate was lower in the first group, but statistically not significant. There was no difference in overall survival rate in these patients between pathological and normal karyotypes. In ANNL group of patients pathological karyotype was observed in 14 of them, with numerical anomalies in 6 patients, structural in 4 patients and both of them - numerical + structural in 4 children. From the whole ANLL group observed 11 (50%) patients died during the follow-up period (9 in relapse and 2 of treatment complications). From 11 died patients in 81.8% pathological karyotype was present. The prevalence of pathological karyotypes was observed in less mature M0-M2 ANLL subtype (71.4%). ANLL patients with pathological karyotype have shown significantly lower event free survival rate (in one of the two statistical log-rank analyses), comparing to the group of ANLL patients with normal karyotype. Overall survival rate was also lower in the first group, but statistically not significant. The presence/absence of CD34 marker expression in blast cells of our group of acute leukemia patients did not show any difference in event free survival and overall survival rates.

Sensitivity and specificity of the fine needle aspiration biopsy of the thyroid: clinical point of view

INTRODUCTION

The rates of sensitivity and specificity of fine needle aspiration biopsy (FNAB) for the diagnosis of thyroid malignancy differ considerably among various reported series. These values are influenced by three factors: (a) whether only clearly positive and negative results are considered, or whether the commonly encountered 10-20% of indeterminate/suspicious ones are included; (b) whether adenomas are considered as neoplasms in one group with carcinomas; and (c) whether only histologically proven cases are used in calculations or whether patients with benign clinical follow-up are included.

AIM

The aim of the study was to evaluate the sensitivity and specificity of FNABs performed at this institution in the last 7 years from the clinical point of view, considering only benign vs. suspicious/malignant FNAB results (indicating surgery), and benign (including adenomas) vs. malignant definitive histology.

STUDY DESIGN

Retrospective study comparing pre-operative FNAB results with definitive histological examination after operation.

PATIENTS

A total of 2492 FNABs were performed in 2100 patients (1875 women and 225 men); their ages ranged from 9 to 85 years, with a median of 46 years. Clinical diagnosis was multinodular goitre in 1330, single nodule in 591, Hashimoto's thyroiditis in 147 and subacute thyroiditis in 32 cases. In 148 instances, the nodule was cystic. A history of previous treatment for carcinoma of the thyroid was present in 12 patients. Five hundred and thirty-six patients subsequently underwent thyroid surgery.

STATISTICS

The values of sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and diagnostic accuracy were calculated.

RESULTS

The sensitivity was 86%, specificity 74%, PPV 34%, NPV 97% and diagnostic accuracy 75%.

CONCLUSIONS

The specificity and positive predictive value are low when fine needle aspiration biopsy results are divided into two categories only (these being indication for surgery or not), and when only suspicious/malignant fine needle aspiration biopsies with subsequent malignant histology are considered to be true positive. Nevertheless, the ability to discriminate 11.7% of patients with a 34% probability of malignancy (suspicious/malignant cytology) from 81.2% of patients (benign cytology) with a probability of only 3% is very helpful.

Expression of CD10, CD19 and CD34 markers in bone marrow samples of children with precursor B-cell acute lymphoblastic leukemia in clinical and hematological remission

Long-term follow-up of the rate of CD10, CD19 and CD34 antigens expression compared with the percentage of lymphocytes and blastic cells in 196 bone marrow specimens of 91 children with early B-cell acute lymphoblastic leukemia has been performed. It was shown that during a five year period there were no significant differences concerning the percentage of CD markers and the percentage of lymphocytes and blastic cells except those in the 4th year of clinical and immunological follow-up--when increase of lymphocytes and CD19 marker percentage have been observed. Consensus, i.e. more than 20% CD markers positivity associated with more than 5% blasts (positive consensus) or less than 20% CD markers positivity combined with less than 5% blasts (negative consensus) was ascertained in 92.8% of cases. Disagreement, i.e. the rate of CD markers over 20% combined with less than 5% blasts was found in 14 (7.2%) patients. This finding present in the initial phase of the disease could be considered as a sign of not complete remission, in contrast to the finding in children who completed chemotherapy and were in long-term hematological remission, in which the increase of CD markers could be considered as a sign of increased regeneration activity of bone marrow after chemotherapy induced medullary aplasia. Anyway, the increase of CD10, CD19 and CD34 antigens in bone marrow samples over 20% should be evaluated with caution. In these cases, mainly in children with long-term hematologic remission the examination should be repeatedly performed and/or more sensitive methods for detection of minimal residual disease should be applied. In control group of 20 children without leukemia the rate of CD markers in the bone marrow was always under 20%.

Is T-cell acute lymphoblastic leukemia still a high risk leukemia in children?

In a group of 21 children with T cell ALL we compared the clinical picture and laboratory finding in a subgroup of 13 patients with less mature (mCD3 negative) and a subgroup of 8 patients with mature (mCD3 positive) phenotypical type and the therapeutic response in relation to the stage of thymic differentiation of the blastic cells as well. We could not find any significant differences concerning the presence or absence of mediastinal thymic mass, organomegaly, WBC count, morphology of the blasts and their acid phosphatase and PAS reaction between cases with less mature and mature type of thymic differentiation. Concerning the therapeutic response, children with mature type of T-ALL have shown at 5 years significantly higher event free survival rate, in comparison with the group of patients with less mature type of T cells. Overall survival rate was also higher in the first group, but statistically not significant.

Phenotypic heterogeneity and aberrant markers expression in T-cell leukemia

For exact determination of lineage assessment there is a need of surface membrane and intracellular (cytoplasmic and nuclear) immunophenotyping performed by flow cytometry. We evaluated in detail the results of surface and intracellular immunophenotyping of 34 T-ALL cases. The great heterogeneity of T-cell differentiation markers has been observed which did not allow relevant subclassification of T-ALL according to the existing subclassification schemes and the proposed three-stage model of physiological T-cell differentiation. Therefore, a simplified classification based on the CD3 marker expression either on cell membrane or in cytoplasm has been created with allocation of T-ALL into two main phenotypic groups. From 34 in detail examined T-ALL cases a great deal-27 (79%) belonged to an immature phenotype (Stage I) and only 7 (21%) expressed more mature phenotype (Stage II). Simultaneously the presence of atypical/aberrant T-cell phenotypes has been studied. We showed that in T-ALL it was possible to specify some cases with leukemia-associated phenotype with coexistence of atypical markers which are absent in nonleukemic cells. In a majority of cases early B-lineage marker (CD10) and in a smaller proportion of them non-lineage associated marker (CD34) were observed. Myeloid marker CD13 was observed in one case of the immature T-ALL, together with CD10 and CD34. As these atypical markers were present through all differentiation stages of T-ALL we obtained a strong evidence that they might represent an abnormal rather than an immature phenotype. The prognostic significance of T-ALL subtypes and aberrant markers coexpression have been discussed. Simultaneously it was shown that quantitative immunofluorescence could provide an additional important diagnostic marker also in T-ALL cases.

Is high dose methotrexate without irradiation of the brain sufficiently effective in prevention of CNS disease in children with acute lymphoblastic leukemia?

We present 5-year results of treatment in 93 children suffering from acute lymphoblastic leukemia using two therapeutic protocols containing multidrug chemotherapy including high dose methotrexate. We could ascertain different results in standard and high risk patients. In a group of 62 children with standard risk we observed improvement in complete remission rate being 98.9% after induction phase of therapy, only one patient died on septicemia. Relapse rate in this group was 21.2% and that 14.7% in the bone marrow and 6.5% in CNS and no testicular relapse at all. In the group of 31 children with high risk leukemia all patients achieved complete remission. Only one of them died on acute pancreatitis due to toxicity. Overall relapse rate in this group was 28.9% with 12.8% of medullary relapse and 16.1% of CNS relapse. The last one was significantly higher than in the previous study when brain irradiation was a part of therapeutic procedure. It seems that this treatment is effective mainly in the standard risk leukemia, however, in the high risk leukemias this procedure appears to be less effective in preventing CNS leukemia. In this group of patients irradiation of the brain need to be enclosed in the therapy.

[Growth and puberty in children after treatment of acute lymphoblastic leukemia]

BACKGROUND

Growth retardation and other endocrine abnormalities were recognized as sequelae of therapy of acute lymphoblastic leukemia (ALL), especially when chemotherapy was combined with cranial irradiation. The aim of our study was to establish growth and pubertal development in the group of children who had been previously successfully treated for ALL.

METHODS AND RESULTS

58 children (30 F, 28 M, age 8-18 y.) in complete initial remission lasting 4-15 y. (m 8 y.) after standard antileukemic therapy (including cranial irradiation) completed 2-9 y. ago (m 3 including y.) were studied. Standard deviation score (SDS) of standing height (SH) to chronological age (CA) and to genetic target height (GTH), index of body proportionality and timing of puberty were followed up. The final height attained 21 girls and 3 boys. The height of the boys differed neither from the average for our men, nor from their GTH. Girls: SH 148 cm-169 cm, SH of 7 girls > or = -1.5 SDS, 8 girls > or = -1.5 SDS to their GTH. The final height didn't reach yet 23 boys and 9 girls. Their SH to CA as well as SH to GTH didn't substantially differ from average. Index of body proportionality > or = 1.5 SDS in 12/30 girls and 6/28 boys. Menarche was already reached in 25 girls in age ranging from 10-15 y. (mean 11.3 y.), what was less than average for our population (13.3 y.).

CONCLUSION

Even the height of prepubertal children under study didn't differ from average, the final height of girls (boys could not be evaluated because of small numbers) was significantly lower as could be expected. We suppose the early ending of puberty as a contributing factor of short stature in girls. Clear tendency to obesity especially among older girls was observed. Children who underwent antileukemic therapy deserve careful endocrinological follow-up.

Immunoradiometric and luminescence immunoenzymometric assay of human thyrotropin from dried blood spots for screening of neonatal hypothyroidism

Two monoclonal antibodies to thyrotropin prepared in our laboratory were employed for the development of two-site immunometric assays in two modifications for the estimation of human thyrotropin in dried blood spots designed for the screening of neonatal hypothyroidism. The immunoradiometric assay using the second antibody labelled with 125I is simple and fast (one incubation step lasting 2 h). The detection limit of 1 mU/l and the absence of the hook effect up to a concentration of more than 1000 mU/l are optimal for neonatal screening; the presence of other glycoprotein hormones does not interfere with the assay. In the luminescence immunoenzymometric assay the second antibody is labelled with peroxidase. In spite of the two-step configuration the method is fast (4.5 h) and enables specific determination of thyrotropin levels in the range of 2.4-1100 mU/l. The conditions and properties of both immunometric assays described are comparable with the time-resolved immunofluorometric assay widely used in Europe.

[Differentiating parathyroid adenoma from microfollicular thyroid nodule in fine-needle aspiration cytology]

Two cases of fine needle aspiration cytology of parathyroid adenoma were not misinterpreted as microfollicular nodules of the thyroid. Discrimination of those two lesion is a diagnostic pitfall in cytological material. Authors pointed out criteria for differential diagnosis. Radioimmunoanalysis of parathormone in aspirate served as a simple, safe and reliable method in these cases.

Fluconazole in children: first experience with prophylaxis in chemotherapy-induced neutropenia in pediatric patients with cancer

In an open multicenter, prospective study fluconazole (FLU) was administered to prevent fungal infection in 22 neutropenic, 2- to 14-year-old children. Of 4 failures, one was infected with an Aspergillus spp., one with Candida krusei and one with Candida (Torulopsis) glabrata. One failure was of bacterial origin. Those patients with mycoses who failed on fluconazole were successfully treated with other antifungals. In 4 patients transient elevation of liver enzymes was observed. This is the first reported trial using FLU in prophylaxis against fungal infection in neutropenic pediatric patients, where 18/24 children did not present any evidence of mycotic infection using FLU in daily doses of 1-4 mg/kg.

[Conn's syndrome in tumors of the adrenal cortex]

During the period from Jan. 1 1989 to June 30 1992 at the Urological Clinic in Hradec Králové three women with cortical adenomas were treated, the tumour being the cause of primary hyperaldosteronism. The age of the patients was 25-40 years, in one woman the tumour was on the right side, in two on the left side. All patients complained of marked muscular weakness, fatigue, one woman developed cramps of the hands when working and another patient was repeatedly hospitalized at the neurological department on account of attacks of weakness. In one patient the interval from the onset of complaints to assessment of the diagnosis was 23 years. All patients had complete examinations at specialized departments before operation, in all the diagnosis was established by biochemical examinations and CT. In all instances minor tumours--diameter 2-3 cm--were involved which were easily removed by surgery. The postoperative course in all patients was without complications.

[Broncho-Vax and IRS 19 in the treatment of recurrent respiratory tract inflammation in children]

A group of 80 children with relapsing infections of the respiratory pathways (a minimum of three during the previous period) were investigated during the first year of the investigation (1987-88) with regard to the number and duration of the disease, absence from school, antibiotic consumption and use of bronchodilatating agents. In the subsequent year 1988-1989 the children were divided into a group treated with Broncho-Vaxom, a group treated with IRS 19 and a control group. Before the onset of administration and then every two months functional examinations of the lungs were made in the children. At the beginning of treatment and after its termination some immunological and laboratory values were examined. The effect of treatment was evaluated also subjectively by the parents and physician. Both preparations had a favourable effect on prevention of relapses of respiratory infections. This effects was more favourable after Broncho-Vaxom, in particular in prevention of inflammations of the lower respiratory pathways. IRS 19 eliminates relapses of infections of the upper respiratory pathways sooner.

[Long-term clinical experience with spherocytic hemolytic anemia in children]

The author investigated during a 15-year period 27 children with spherocytic haemolytic anaemia. In 20 children the disease was familial. The initial symptoms were jaundice and anaemia. In six children the disease was manifested by severe neonatal jaundice and in four an exsanguination transfusion was made. Of five older children three were at first treated for infectious hepatitis. The anaemic syndrome was in the foreground of the clinical picture in 16 children, incl. 10 where it was present already in infant age. In 24 children splenectomy was performed, usually after the age of 6 years. For prophylaxis of bacterial infection the splenectomized children were given penicillin preparations for a period of three years. The OPSI syndrome was not recorded.

[Abnormal CT brain scan during acute lymphoblastic leukemia in children]

The results of CT brain scans were evaluated in 96 children with acute lymphoblastic leukemia in different stages of the disease. Practically normal findings were recorded at establishing the diagnosis (17 children), with the exception of infiltration of the brain and meninges in one patient. Examinations performed after induction chemotherapy (31 children) revealed abnormal CT scans in 55% of the children concerning most frequently dilatation of the cerebrospinal fluid pathways and exhibiting less frequently hypodense foci in the white matter. At check-up examinations after 9 months (following prophylaxis of CNS leukemia) these deviations from the norm had disappeared in some patients, in others they persisted and in the rest of the patients they were found to be aggravated. Examinations carried out several years after treatment completion (40 patients) showed abnormal CR scans in 43% of the patients. These involved particularly derangements in the density of the white matter which were of leuko-dystrophic type and atrophic changes characterized by dilatation of the cerebrospinal fluid pathways. The recorded changes in the CT brain scans were more pronounced in patients with high-risk forms of leukemia and intensive prophylaxis of CNS leukemia.

[The status of natural immunity in children with acute lymphoblastic leukemia evaluated by long-term monitoring of complement-dependent bacteriocidal antibodies against B. anthracis and its relation to prognosis]

The authors investigated the function of the time factor as regards changes of bacteriocidity levels of serum against B. anthracis. Due to the fact that anthrax has not occurred in this country for several decades, we can speak of an investigation of natural immunity in the wider sense of the word. In the course of 15 years the authors collected repeatedly blood specimens from 53 children with ALL before, during and after treatment. Active sera were examined by quantitative titration by means of microbes labelled with 51Cr. The results of the investigation revealed that mean values of bacteriocidity calculated from all specimens and for each child separately are higher in the groups of children with a favourable course of the disease, as compared with children with an adverse course of the disease. It was also found that in a high percentage (78%) patients with long-term remission of leukaemia have a rising trend of bacteriocidity and the majority of children with a relapse of the disease (69%) had a bacteriocidity of serum with a declining trend (p = 0.01). The prognostic value of the test is unequivocally apparent from the results of the "life table" analysis. Children with an event free survival as well as the number of surviving children was significantly higher in the group with a rising trend of bacteriocidity than in patients with a declining trend of bacteriocidity (p = 0.008 and p = 0.02).

[Somatic development after successful therapy of acute lymphoblastic leukemia]

The authors evaluated 55 subjects after successful treatment of acute lymphoblastic leukaemia in childhood as regards height, body weight and sexual maturation. In 23 the final height could be evaluated, which was somewhat lower than the mean height of the population, lower than could be expected according to the genetic potential and height before the diseases with a more evident deficit in women. There was an obvious tendency to overweight. Early onset of menarche was recorded.