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

BACKGROUND

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

MATERIAL/METHODS

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

RESULTS

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

CONCLUSIONS

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

Repeated cycles of peptide receptor radionuclide therapy (PRRT)--results and side-effects of the radioisotope 90Y-DOTA TATE, 177Lu-DOTA TATE or 90Y/177Lu-DOTA TATE therapy in patients with disseminated NET

PURPOSE

PRRT is a known tool in the management of patients with disseminated and inoperable NETs. The aim of study was to assess the effectiveness of the repeated cycles of PRRT in patients with disseminated and inoperable NETs.

MATERIAL AND METHODS

Eighty nine patients were included in the PRRT. Among them 16 patients (18%) were qualified for a repeated PRRT cycle due to progression of the disease. In one of the patients qualified for the repeated cycle, PRRT was used as neoadjuvant therapy. The results and side-effects of the repeated cycles of PRRT were analyzed.

RESULTS

Disease stabilization was observed in 10 patients 6 months after the repeated PRRT cycle and in 5 patients after 12 and 18 months. Ten of the patients who had received repeated PRRT cycles died. In the case of neoadjuvant therapy, further reduction of the tumor size was observed, enabling qualification for surgery. Clinically significant reduction in the mean values of morphological parameters was not observed. Only after 12 and 18 months the mean values of creatinine levels were higher than the normal range (only in 2 patients).

CONCLUSIONS

The repeated cycles of PRRT did not cause a clinically significant increase of the toxicity of PRRT. The changes in kidney and blood morphology parameters were transient. The repeated cycles of PRRT enabled stabilization of the disease.

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

Purpose

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

Methods

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

Results

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

Conclusion

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

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

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

Neuroendocrine tumours of rare location

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

[Current opinions on pathogenesis, diagnostic procedures and management of gastric neuroendocrine tumors]

Gastric neuroendocrine tumors (NET ventriculi) are rare neoplasms of the gastrointestinal tract, increasing in incidence over last fifty years, what partly could be explained by the common use of upper gastrointestinal tract endoscopy. Pathogenesis of the NET ventriculi is not fully understood, however it is well known, that in all NET ventriculi types there is a hyperplasia of enterochromaffine-like cells (ECL) related to different stimuli. NET ventriculi type 1 is related to autoimmunological atrophic gastritis and hypergastrinaemia, NET ventriculi type 2 with hypergastrinemia in the course of Zollinger-Ellison syndrome associated with multiple endocrine neoplasia (MEN 1) syndrome, NET ventriculi type 3 are sporadic tumors not related to hypergastrinaemia, usually with poor prognosis. Localization of tumors and possible metastases, histo-pathological confirmation of the neoplasm type and defining the source of hypergastrinaemia is essential in diagnostic of NET ventriculi. Treatment dependent on the NET ventriculi type is based on endoscopic or surgical tumor excision in type 1 and 2 and surgical radical treatment in type 3. There is an increased interest in the use of somatostatin analogues (SSA) both in type 1 and in cases with dissemination of the disease. Advances in understanding of the pathogenesis and recent development of medical techniques leads to the improvement of diagnostic and therapy in these group of neoplasms.

[Evaluation of cardiovascular autonomic nervous system in ethanol withdrawal]

The aim of the study was to assess the risk factors and state of cardiovascular autonomic nervous system injury in ethanol dependent patients. The group examined consisted of 85 alcoholics (17 females and 68 males) aged from 27 to 68 y (45.7 +/- 8.82) hospitalized at the Ward of Toxicology and Environmental Diseases because of alcohol withdrawal. Ethanol dependence was diagnosed according to ICD -10 criteria, withdrawal syndrome was scored according to CIWA - A scale. A blood ethanol concentration, creatinine, urine, coagulation parameters and liver enzymes activity were measured on admission. Cardiovascular autonomic nervous system was evaluated by standard Ewing battery tests using VariaCardio TF5 system. The parasympathetic system was assessed by the heart rate response to forced breathing, the heart rate response to standing up, and to heart response to the Valsalva maneuver. The sympathetic system was evaluated by the blood pressure response to standing up. The original Ewing normal values were used.

RESULTS

The mean duration of ethanol dependence was 13.7 +/- 8.2 y. In 92% of examined patients heavy and in 8% moderate ethanol withdrawal syndrome was diagnosed. The mean blood ethanol concentration was 1.07 +/- 1.21g/l. Liver injury was diagnosed in 43.5% of the examined group. No changes in autonomic battery tests were found only in 28.2% of the examined subjects. Early parasympathetic damage was stated in 23.5%, definite parasympa-thetic damage in 44.7%, combined para-sympathetic and sympathetic damage was diagnosed in 3.5% of patients examined. The relative risk for parasympathetic and sympathetic system injury rose together with CIWA - scoring, blood ethanol concentration on admission (OR = 1,4 95% CI: 0,81 +/- 2,4), and when GTP activity was three times greater than normal (OR = 1.2 95% CI: 0.92 +/- 1.7).

Effectiveness of the iodine prophylaxis model adopted in Poland

OBJECTIVE

Most of the Polish territory has been classified as an iodine-deficient and endemic goiter area according to the International Council for Control of Iodine Deficiency (ICCIDD) criteria. In 1997 the obligatory model of iodine prophylaxis was implemented. Our investigations were aimed at the effectiveness of iodine prophylaxis in Poland.

METHODS

We assessed urinary iodine excretion and goiter prevalence in 5663 children aged 6-12 yr. The population of children from the same 27 schools was investigated from 1992 to 1994 (1406 girls and 1244 boys) and from 1999 to 2005 (1563 girls and 1450 boys) using identical laboratory and ultrasound methods.

RESULTS

We found significant increase in iodine urinary concentration (median 52 microg/l vs 93 microg/l, p<0.001) with accompanying drop in goiter prevalence (29.6% vs 5.2%, p<0.001) after implementation of iodine prophylaxis. Iodine excretion distribution changed significantly after 1997 with an increase in the percentage of children with iodine urinary concentration above 100 microg/l from 10.8% to 45.4%, respectively. A significantly higher iodine urinary concentration was observed in lowlands compared to uplands both before and after implementation of iodine prophylaxis (median, 50 microg/l vs 57 microg/l and 86 microg/l vs 114 microg/l, respectively, p<0.001). The goiter prevalence did not differ between girls and boys from 1992 to 1994 (28.8% vs 30.5%, p=0.35) and 1999 to 2005 (5.5% vs 4.9%, p=0.45).

CONCLUSIONS

Implementation of the new model of iodine prophylaxis in Poland in 1997 has led to significant increase in iodine urinary concentration and decrease in goiter prevalence among Polish schoolchildren. In the youngest group of children (6-8 yr olds), prevalence of goiter decreased to 3.2%--i.e. below endemic levels.

[Somatostatin receptors expression (SSTR1-SSTR5) in pheochromocytomas]

Confirmation of somatostatin receptors (SSTR) expression in neuroendocrine tumours has changed their modern diagnosis and therapy, and starts to influence the approach to pheochromocytomas. In vitro studies have revealed the SSTR expression in pheochromocytomas, particularly subtype 2A and 3. They also have indicated that their confinement to cell membranes is essential for successful diagnostics with the use of somatostatin analogues. Scintigraphy with radiolabeled somatostatin analogues is nowadays an approved complementary method of pheochromocytoma localization, particularly the malignant ones. Cell culture studies have indicated that the commercially available somatostatin analogues are able to control tumour growth and secretion. Unfortunately these results have not been confirmed by clinical studies. It seems that the analogues with the broader affinity to sstr may be a good therapeutic option for pheochromocytoma patients. Promising results of radiotherapy with labeled analogues have been recently announced.

Two rare cases of pituitary metastases from breast and kidney cancers

Pituitary metastases, though very uncommon, may cause endocrine and neurosurgical problems. The clinical manifestation of such metastases is highly variable. Most of the metastatic pituitary tumours are oligosymptomatic. We report two cases of metastatic pituitary lesions. The first patient, a 52-year old female, with metastatic breast cancer, developed symptomatic anterior pituitary insufficiency. The second patient, a 46-years old female presented with signs and symptoms of pituitary apoplexy and visual impairment due to metastasis from renal cancer. None of them was diagnosed with diabetes insipidus, the most common manifestation related to pituitary metastatic mass.

Increased prevalence of hyperthyroidism as an early and transient side-effect of implementing iodine prophylaxis

Objective

To assess the prevalence of hyperthyroidism just after implementation of iodine prophylaxis among adults from an area with iodine deficiency.

Study design and subjects

A total of 1648 adults (age 16 years and older) were sampled from an area of southern Poland during two nationwide epidemiological surveys. Of these, 1424 adults with negative medical history for thyroid disorders qualified for final analysis. The authors compared thyroid dysfunction in participants prior to (1989–1990) and after implementation of iodine prophylaxis (1997–1999).

Setting

The southern part of Poland.

Results

We found an increase in the serum concentration of anti-thyroid microsomal antibodies from 4.9% in the years 1989–1990 to 12.1% after introduction of iodised household salt (P < 0.0001). The prevalence of hyperthyroidism (defined as thyroid-stimulating hormone < 0.4 μU ml− 1) significantly increased in the equivalent period from 4.8 to 6.5% (P = 0.009).

Conclusions

We concluded that a sudden rise in iodine intake after implementation of iodine prophylaxis among adults from the area with iodine deficiency may lead to an increase in thyroid autoimmunity and prevalence of hyperthyroidism. Those possible early side-effects appear to be only temporary and are acceptable when compared with the evident benefits of adequate iodine intake.

Iodine prophylaxis--the protective factor against stomach cancer in iodine deficient areas

BACKGROUND

Poland has one of the highest death rates for stomach cancer in Europe. Moderate iodine deficiency and in consequence high goitre prevalence led to the implementation in 1996 of a very efficient mandatory model of iodine prophylaxis, based on household salt iodisation (30 +/- 10 mg KI/1 kg of salt).

AIM OF THE STUDY

The aim of the study was evaluation of incidence rate of stomach cancer and its possible relation to increased iodine consumption in the years 1992-2004.

METHODS

Iodine supply and effectiveness of iodine prophylaxis were evaluated on the basis of comparative analysis of goitre prevalence and ioduria in schoolchildren. To allow comparison between time periods with varying population age structures, the incidence rates of stomach cancer were standardized for age, using the "world standard population". The direct standardization method has been applied. For each sex, the time-trend of incidence rates was shown in graphs over the years 1991-2004.

RESULTS

Evident increase in iodine consumption in this period of time was proved by rise in percentage of schoolchildren (6-8 years old) with ioduria above 100 microg/l from 11.4% in 1992-1993 to 52.9.1% in 2003. It was correlated with the decrease in goitre prevalence from 18.8% to 3.2% respectively. The 24-h thyroid uptake of (131)I in investigated population fell from 45.5% in 1986 to 26.8% in 1998. In Krakow the standardized incidence ratio of stomach cancer for men decreased from 19.1 per 100,000 to 15.7 per 100,000, and for women from 8.3 per 100,000 to 5.9 per 100,000 in the years 1992-2004. A significant decline of average rate of decrease was observed in men and women (2.3% and 4.0% per year respectively).

CONCLUSION

Observed association between improved iodine supply and decrease of incidence of stomach cancer could indicate the protective role against stomach cancer of iodine prophylaxis in iodine deficient areas--further studies are necessary.

[A case of GH and TSH secreting pituitary macroadenoma]

A case of GH and TSH secreting pituitary macroadenoma is reported. A 45-year-old female presented clinical features of acromegaly (the abnormal growth of the hands and feet, with lower jaw protrusion), diabetes mellitus, hypertension, nodular goiter and hyperthyroidism of unclear origin. NMR pituitary imaging revealed intra and extrasellar tumor. The laboratory examinations showed very high plasma levels of GH and IGF-1 and normal level of TSH coexisting with high plasma levels of free thyroid hormones. Pharmacological pretreatment with somatostatin analogues caused the substantial reduction of GH and TSH plasma levels. Histological and immunohistochemical examination of the tissue obtained at transsphenoidal surgery showed GH and TSH secreting adenoma. The laboratory examinations after surgery showed normal GH and IGF-1 plasma levels and reduced insulin requirement, what indicates radical operation. The very low plasma levels of TSH and free thyroid hormones after surgery and immunohistochemical examination suggest central hyperthyroidism due to TSH secreting pituitary tumor (thyrotropinoma).

[Diagnostic problems with recognition of primary hyperparathyroidism]

The aim of our study was to compare the results of biochemical and imaging investigations with histopathological diagnosis in operated patients with primary hyperparathyroidism. 46 subjects were included into the study, pathologically demonstrated as parathyroid adenoma--23 subjects, parathyroid hypertrophy--16, parathyroid carcinoma--2 and in 5 patients parathyroid gland was not found in resected tissue. The most frequent complications of primary hyperparathyroidism in our group were osteoporosis (87%) and nephrolithiasis (64.1%). 99mTc-MIBI imaging described as a parathyroid adenoma or parathyroid hypertrophy were confirmed pathologically in 52 and 57.1%, respectively. Three typical symptoms of primary hyperparathyroidism assessed in our study (hypercalcemia, hypercalciuria and increased concentration of parathormone) were observed only in about 50% patients with histopathological diagnosis of adenoma and hypertrophy. The lowest average calcium serum level (2.87 mmol/l), urinary calcium level (7.8 mmol/24h) and parathyroid hormone concentration (209.4 pg/ml) were observed in patients with parathyroid adenoma, the highest levels of these parameters were noticed in patients with parathyroid carcinoma (3.41 mmol/l; 14.6 mmol/24h; 687.8 pg/ml, respectively), patients with parathyroid adenoma were characterized by intermediate values (2.98 mmol/l; 9.7 mmol/24h; 285.5 pg/ml, respectively). After parathyroidectomy lowering in average calcium serum level (2.94 vs. 2.16 mmol/l), parathyroid hormone concentration (244.45 vs. 54.15 pg/ml) and increasing in average phosphate serum level (0.81 vs. 1.04 mmol/24h) were observed in our group. Finally, using different biochemical and imaging investigations is necessary for proper recognition of primary hyperparathyroidism due to occurring of oligosymptomatic cases.

[Analytical problems of iodine defficiency examination in Polish Nation-wide deficit control program]

The environmental iodine deficiency has been a serious problem in the Polish health care system for many years. In many European countries the prevention of iodine deficiency-related health deficits in population scale is based on edible salt supplementation with KI. In the decade of the 80-ties the iodine supplementation program in Poland was stopped, which has caused a subsequent increase in prevalence of goiter and iodine deficiency-related hypothyreosis. These diseases were observed in many regions of Poland, including the areas beyond regions of formerly known iodine deficiency endemias. In order to control the whole Polish population, iodine consumption deficit in1991 the "Polish Program of Iodine Deficiency Control and Prevention of Iodine Deficiency-related Disorders" has been established in the year 1991. In 1992--1996 a common iodine supplementation of salt used for general consumption was 20 mg KI/kg of NaCl, and in 1997 the mandatory supplementation of salt was 30 (+10) per kg of salt which has been introduced for the whole country. This paper reports the results of iodine excretion assays in school children 6-12 years old, in the years 1993--94, 1996--97 and 1999--2002 respectively. The obtained collections of iodine urine concentrations have shown distributions with a remarkable rightward skewness. Normalization of distributions required logarythmic transformation. The quartile values obtained for data collections from years 1992--94, 1996--97 and 1999--2002 have shown that in 5-7 years of iodine deficiency prevention program yielded increase in iodine excretion in morning urine samples by about 37.8 microg, while the iodine excretion median values increased from 63.5 mg/L in years 1992--1994 to 94.0 mg/L in years 1999--2001, respectively. The lower limits of iodine excretion ranges calculated as the mean value minus 2SD of transformed data for the years 1992--1994 amounted to: 7.74 mg/L and for the years 1999--2001 amounted to 14.1 microg/l, respectively. Assessing percent of children obtaining low iodine suplementation then recommended (below 50 mg/L in urine sample) amounted to 35.8% in years 1992--1994 and 15.4% in years 1999--2001 respectively.

[Assessment of early immunosuppressive therapy in the prevention of complications of Graves' disease]

Regardless the autoimmune origin of Graves' disease, the preferred method of its treatment remains antithyroid drug administration. Use of immunosuppressive agents (mostly steroids) is still limited to the therapy of disease complications, such as proliferative ophthalmopathy. The aim of the study was to assess the influence of early immunosuppressive treatment of autoimmune thyrotoxicosis with azathioprine on the course of the disease and the incidence of its complications. The study comprised 64 patients (47 females and 17 males aged 20-43 years) for the first time diagnosed with Graves' disease. The subjects were randomised into two groups. Group I consisted of 28 patients treated only with antithyroid drugs, the remaining 36 subjects additionally receiving azathioprine were included into group II. The dose of both drugs was adjusted during the treatment according to metabolic status of each patients. The treatment was continued for 8-14 months, the follow-up duration after therapy withdrawal was 5 years. Euthyreosis was achieved in all patients 2-8 weeks after treatment initiation. No drug intolerance symptoms were observed in group I. In four patients additionally treated with azathioprine, gastrointestinal side effects or leucopenia were present. The disease relapse was observed during the follow-up period in 15 (53.5%) patients of group I and in 3 (8.3%) of group II, the difference was statistically significant (p<0.01). Only one patient receiving additionally azathioprine presented ophthalmic symptoms compared with seven subjects (25%) treated only with antithyroid drugs (p<0.001). The patients of group I were also more frequently referred to surgical treatment due to rapid goitre growth (accordingly 5 (17.8%) and 1 (2.7%) patients, p=0.07), the difference between both groups not being statistically significant.

CONCLUSIONS

Additional early immunosuppressive treatment significantly decreased frequency of Graves' disease complications and thyrotoxicosis recurrence. The use of azathioprine may be advised in patients with contraindications to the radical Graves' disease treatment and in prophylaxis of its complications.

[Evaluation of accordance between cytological and histopathological findings in selected thyroid tumors]

The thyroid fine-needle aspiration (FNA) is the decisive examination in the preoperative diagnostics of thyroid nodules. Different cytohistologic studies have revealed that the accuracy of FNA for thyroid nodules varied from 69% to 94%. The aim of our study was to compare the results of FNA with regard to final histopathological diagnosis among patients with follicular tumor, Hurthle cell tumor or papillary carcinoma in FNA. We retrospectively analyzed medical documentation of 51 patients (mean age 57.9 years, 49 women and 2 men) from the Endocrinology Department from 1997 to 2002 years. Based on FNA 29 patients were diagnosed as having follicular tumor, 10 as having Hurthle cell tumor and 12 as having papillary carcinoma. Carcinoma was detected histopathologically in 38% of patients with follicular tumor. Follicular carcinoma was detected histopathologically in 10% of patients with Hurthle cell tumor. Cytological diagnosis was confirmed histopathologically in 66.8% of all patients with papillary carcinoma in FNA. In accordance with our results the confirmation of malignant neoplasm can be expected in more than 80% of cases with papillary carcinoma in cytological examination. In case of follicular or Hurthle cell tumors the frequency of malignant neoplasm was less than 40% and 10% respectively.

[Postprandial hypotension and gastric emptying in longstanding diabetes mellitus]

Postprandial hypotension is commonly defined as a decrease in systolic blood pressure of 20 mmHg and more within 2 hours after meal ingestion. It was described in autonomic nervous system failure of different origin, among others in diabetes mellitus. Pathomechanism of postprandial hypotension is not entirely understood. The rol of gastric emptying disorders is considered as an important factor. The aim of the study was to evaluate the concordance between gastric emptying and postprandial blood pressure changes in diabetic patients. The study involved 67 subjects (26 males, 41 females, mean age: 47.5 +/- 16.2 years) diagnosed either with diabetes mellitus type 1 or 2 (disease duration: 13.3 +/- 8.8 years) and treated with diet and insulin injections. Postprandial hypotension was recognised based on results of automatic blood pressure recordings within 90 minutes after test meal ingestion, according to the criterion mentioned above. Gastric emptying was assessed scintigraphically. The parameters evaluated were: gastric half emptying time (T1/2 max) and residual activity registered over stomach area at 45 minute of the study. Both blood pressure monitoring and gastric emptying were assessed concurrently. In investigated patients mean fall in systolic blood pressure of 17.7 +/- 11.7 mm Hg was recorded at 48.0 +/- 13.7 min of the study. Based on systolic blood pressure monitoring results patients were divided into two groups: group A of 39 patients (58.2%) without postprandial hypotension, and group B of 28 patients (41.8%) with pathological reaction of systolic blood pressure to meal. The average decrease in systolic blood pressure was 8.9 +/- 4.4 mm Hg in group A and 30.0 +/- 6.2 mmHg in group B, the difference was statistically significant (p < 0.001). Gastric emptying parameters in both groups did not differ significantly (T1/2 max: group A 68.4 +/- 31.1; group B 70.8 +/- 39.1 min, p = 0.96; residual activity over stomach area at 45 min of the study: 64.5 +/- 18.6% and 62.6 +/- 24.3% accordingly, p = 0.80). No statistically significant correlation between gastric emptying half time (T1/2 max) and magnitude of postprandial systolic blood pressure fall was noted (Spearman's correlation co-efficient R: -0.041, p = 0.74). Statistically significant correlation was found between T1/2 max value and time in which systolic blood pressure reached its nadir (Spearman's correlation co-efficient: 0.527, p < 0.0001).

CONCLUSIONS

Gastric emptying was not recognised as an important factor influencing the magnitude of postprandial hypotension in diabetic patients, however it may significantly change the dynamics of postprandial blood pressure decrease.

[Nonfunctional pituitary adenoma and pulmonary sarcoidosis--a case report]

A case of the coexistence of nonfunctional pituitary adenoma and pulmonary sarcoidosis is reported. 39 years old female presented symptoms of a pituitary-gonadal axis insufficiency, visual deficit and dizziness. CT pituitary imaging revealed large intra and extrasellar tumour. Histological examination of the tissue obtained at transsphenoidal surgery showed chromophobic adenoma. Hypopituitarism and transient diabetes insipidus occurred after the surgery. The adequate replacement therapy with hydrocortisone and sex steroids was introduced. At the time of the pituitary tumour diagnosis enlargement of pulmonary lymph nodes was also observed. Based on histological examination of tracheal and bronchial epithelium specimens obtained during bronchoscopy the diagnosis of pulmonary sarcoidosis was made. No other systemic sarcoidosis localisation was confirmed. Histological re-evaluation of adenoma showed no noncaseating granuloma tissue. The overlapping symptoms of pituitary adenoma and other intrasellar masses may result in diagnostic difficulties, particularly in the presence of systemic disorders in which this gland may be involved.

Prevalence of goiter in schoolchildren--a study on the influence of adequate iodine prophylaxis in Poland

Poland has been known as an area with iodine deficiency. Surveys carried out in 1992/1993 and 1994 revealed that the voluntary model of iodine prophylaxis introduced in 1986 was ineffective. In 1997 a new model of iodine prophylaxis based on obligatory household salt iodization has been implemented. In order to assess its effectiveness new studies were undertaken in 1999-2001. The study involved 1471 school-children aged 6-15 years from 12 sites. In every subject thyroid volume by means of ultrasound and urinary iodine concentration were assessed. The results were compared with data obtained from the same schools in the 1992/1993 survey. Between 1992/93 and 1999/2001 goiter prevalence decreased from 14.5% to 5.2% (p<0.05) and median urinary iodine concentration increased from 56 microg/l to 103 microg/l (p<0.05). A decrease in goiter prevalence was observed in 6 sites with moderate goiter endemia, whereas the changes in goiter prevalence were statistically insignificant in other 6 sites. Three sites were characterized by goiter prevalence close to 5% before and after implementing the obligatory model of iodine prophylaxis. Goiter prevalence in the remaining three sites remained within the same limit of 7-10%, in spite of observed ioduria increase. The Authors conclude that the Polish model of obligatory iodine prophylaxis ensures efficient iodine supplementation and this is confirmed by a significant increment in ioduria. The effect of this model on thyroid volume is evident in moderate goiter endemia areas. Slight changes in goiter prevalence in mild goiter endemia regions need further monitoring and considering other factors affecting thyroid volume.

[Pituitary tumors: hormonal status and immunohistochemical evaluation]

New imaging modalities and hormonal diagnostic improvement have markedly increased the number of newly recognized pituitary tumours. Introduction of immunohistochemical assays in histopathological diagnostics of pitutary adenomas resulted in better understanding of pathology and clinics of these neoplasms. The aim of the study was to correlate the hormonal status and hematoxylin-eosin staining results with immunohistochemical staining of pituitary tumours. The study included 40 patients aged 43.8 +/- 18.3 years, diagnosed with a pituitary tumour in the Department of Endocrinology Collegium Medicum UJ, who subsequently underwent trans-sphenoidal surgery in the Department of Neurosurgery Collegium Medicum UJ. The serum pituitary hormone levels were assessed by means of radioimmuno-assays. The surgically obtained tumour tissue was evaluated both by hematoxylin-eosin and immunohistochemical staining. Using traditional staining 33 patients were diagnosed with chromophobic adenoma, 1 with basophilic adenoma, and remaining 6 with eosinophilic tumour. Immunohistochemical assays were ACTH-positive in 16, TSH-positive in 7, GH-positive in 14 and PRL-positive in 17 cases. In 15 subjects immunohistochemical staining was positive for at least two pituitary hormones. In 34 of 54 patients with positive immunohistochemical staining results, no increase in corresponding pituitary hormone serum levels was observed. In 5 of 9 patients with negative immunohistochemical staining, no increase in serum hormone level was noted, remaining 4 were characterized by hyperprolactinaemia. Tumour cells were ACTH-positive in 5 of 6 patients with elevated serum ACTH levels and GH- or TSH-positive in all cases of increased levels of these hormones. Only 6 of 15 subjects with hyperprolactinaemia revealed positive PRL immunohistochemical staining.

CONCLUSIONS

Positive immunohistochemical staining often do not correlate with elevated basal serum pituitary hormone levels, which may be related to either impaired synthesis or excretion of the hormones by tumour cells. Increased serum levels of ACTH, TSH or GH are usually connected with positive immunohistochemical staining results. Hyperprolacinaemia in cases of PRL-negative assays arises from PRL secretion defects caused by the tumour presence itself.

Influence of iodine deficiency and iodine prophylaxis on thyroid cancer histotypes and incidence in endemic goiter area

The aim of the study was to evaluate the correlation between thyroid cancer histotype and incidence rate (IR) and iodine nutrition level in two endemic goiter areas: the districts of Krakow and Nowy Sacz. The suspension of iodine prophylaxis in Poland in 1980 resulted in increased goiter prevalence in schoolchildren and adults and elevated TSH levels in newborns in the early 1990s. Since 1992 a rise in thyroid cancer IR was observed. Thyroid cancer IR in the Krakow population was 2.22 in 1986; 3.62 in 1995 and 6.02 in 2001; in Nowy Sacz: 1.52; 2.59 and 3.88 respectively. In 1986 papillary/follicular cancer ratio in both areas was about 1.0--the value typical of iodine deficient areas. After restoring the obligatory iodine prophylaxis in 1997, a significant decrease in elevated TSH concentration in newborns and urinary iodine concentration increase in schoolchildren were observed. A relative rise in the incidence of papillary thyroid cancer and decrease in follicular cancer, resulting in rise in papillary/follicular thyroid cancer ratio up to 5.9 in 2001 was also observed. Since 1999 no further thyroid cancer IR increase was noted. In conclusion, a significant increase in differentiated thyroid cancer IR was observed in association with the iodine prophylaxis suspension. Changes in thyroid cancer histotypes in 1986-2001 and a significant decrease in incremental rate of differentiated thyroid cancer probably reflect the influence of effective iodine prophylaxis. The significant difference between IR of thyroid cancer incidence in the districts of Krakow and Nowy Sacz may be related to differences in the exposure to radiation after the Chernobyl accident.

[Postprandial hypotension and autonomic neuropathy in diabetic patients]

Postprandial hypotension is commonly defined as the decrease in systolic blood pressure of 20 mm Hg and more, observed within 2 hours after meal ingestion. This phenomenon was described in subjects with comprised function of autonomic nervous system. However, the data on its prevalence in diabetic patients are scarce. The aim of the study was to assess the concordance of postprandial hypotension and autonomic cardiovascular neuropathy in diabetes mellitus. The study included 67 patients (26 males, 41 females, mean age: 47.5 +/- 16.2 years) with diabetes type 1 or 2 (mean disease duration: 13.3 +/- 8.8 years), treated with diet and insulin injections. Postprandial hypotension was diagnosed based on results of automatic blood pressure recordings performed within 90 minutes after test meal ingestion. Tests of Ewing's battery were used to evaluate autonomic cardiovascular neuropathy.

RESULTS

Mean postprandial decrease in systolic blood pressure of 17.7 +/- 11.7 mm Hg was noted at 48.0 +/- 13.7 min after meal ingestion. The study patients were divided into 2 groups based on results of systolic blood pressure recordings. In group A of 39 subjects (58.2%) the mean fall in systolic blood pressure of 8.9 +/- 4.4 mm Hg was observed. In group B of 28 (41.8%) subjects fulfilling the criteria of postprandial hypotension systolic blood pressure decreased after the meal of 30.0 +/- 6.2 mm Hg, the difference between groups was statistically significant (p < 0.001). Autonomic cardiovascular neuropathy was recognized in 41 (61.2%) of the study patients. The more advanced neuropathy was stated in group B (neuropathy scale score: group A--1.54 +/- 1.48 points, group B--5.11 +/- 1.93 points, p < 0.001). Statistically significant correlation between the magnitude of postprandial systolic blood pressure fall and cardiovascular neuropathy scale score was noted (Spearman's correlation co-efficient R: -0.612: p < 0.01). Postprandial blood pressure fall correlated significantly with orthostatic systolic blood pressure changes (correlation co-efficient R: 0.610; p < 0.001).

CONCLUSIONS

Postprandial hypotension is an important symptom of diabetic cardiovascular neuropathy. It is recommended to include postprandial blood pressure measurements in diagnostic algorithm of autonomic nervous system dysfunction in diabetic patients.

[Unilateral exophthalmos during the course of cavernous sinus thrombosis: a case report]

Ophthalmopathy, particularly its infiltrative form, is considered a characteristic feature of Graves' disease. However many other also life-treating conditions may be manifested as unilateral exophthalmos and lead to diagnostic problems. A case of a sixty six-year old patient with asymmetric exophthalmos and rapidly decreasing vision acuity is reported. Thyroid eye disease was suspected due to clinical symptoms (diplopy, impaired right eye motion) and thickening of extraocular muscles in ultrasound imaging. Further follow-up and orbits as well as head MRI imaging led to the final diagnosis of cavernous sinus thrombosis, complication of acute maxillary sinusitis.

Incidence of thyroid cancer in the selected areas of iodine deficiency in Poland

The aim of the study was to evaluate the incidence rate (IR), trend and histotype of the differentiated thyroid cancer in the selected areas with varying iodine deficiency. The study was carried out in three areas: Krakow, (Carpathian endemic goiter area with 1.99 million mixed rural and urban population), Gliwice (Upper Silesia--moderate iodine deficiency area mostly industrial with 4.89 million inhabitants) and Olsztyn (slight iodine deficiency area, mainly rural with 0.77 million inhabitants). Between 1990 and 2001, in the study area 2691 newly diagnosed cases of malignant neoplasms of the thyroid gland were registered. In over 80% of patients it was differentiated thyroid cancer: mainly in women over 40 years, with F/M ratio 5.8. The highest percentage of papillary cancer 72.9% was observed in Olsztyn and lowest--50.0%--in Krakow and Nowy Sacz districts. In this period of time incidence rate of differentiated thyroid cancer in women increased in Kraków, Gliwice, and Olsztyn from 1.51 to 9.34 in 1998 1.27 to 5.74 in 1999 and from 2.52 to 11.35 in 2001 respectively. In the youngest (0-20 years) age group no significant increase of IR was observed. Between 1998 and 2001 the dynamics of increase of the thyroid cancer incidence markedly diminished. In conclusion it was hypothesised that an increase in IR of differentiated thyroid cancer in the study area was caused mainly by the suspension of iodine prophylaxis in 1980 and was diminished by the introduction of an obligatory model of iodine prophylaxis in 1996/1997. It was modified in terms of histotype and dynamics of increase by exposure to ionizing radiation. A very specific group at risk on the population level were women aged 20-40 years in the reproductive age exposed to iodine deficiency after suspension of iodine prophylaxis in 1980 and to radiation after the Chernobyl accident in 1986.

[Co-occurrence of diabetic gastropathy and cardiovascular vegetative neuropathy in patients with diabetes type 1. ]

The occurrence of autonomic neuropathy in patients with diabetes is associated with increased incidence of cardio-vascular events and increased mortality. The character of such process is not clear yet and the question if the damage to autonomic nerves equally involves particular organs and systems is open. The aim of the study was to assess the concordance of cardio-vascular neuropathy with diabetic gastropathy in type 1 diabetic patients. The study involved 42 subjects with type 1 diabetes mellitus (age 36.7 +/- 8.3 years; duration of the disease 14.8 +/- 33 years). Gastric emptying of solid food was assessed scintigraphically. T1/2 max and residual isotope activity (expressed as the percentage of initial value) at 45th minute of the study were estimated. Autonomic cardio-vascular neuropathy was assessed based on the Ewing battery tests results.

RESULTS

11 of all subjects (group A) showed normal or increased gastric emptying of solid foods (T1/2 max 36.6 +/- 9.3 min, residual activity 39.6 +/- 12.1%) and 31 remaining subjects (group B) demonstrated delayed gastric emptying (T1/2 max 89.2 +/- 11.4 min, residual activity 74.6 +/- 5.2%), which was regarded as diabetic gastropathy symptom. 31 (74%) of all subjects were diagnosed with cardio-vascular neuropathy, 18 of them (43%) showed early autonomic neuropathy and remaining 13 (31%) presented decided cardio-vascular neuropathy. In group A2 (18%) subjects were diagnosed with early and 5 subjects (45%) with decided neuropathy. In group B early and decided autonomic neuropathy was present in 16 (51%) and 8 (26%) subjects. No statistically important difference between both groups was found.

CONCLUSIONS

The results of the study support the thesis of a disseminated nature of the diabetic autonomic neuropathy and of not concomitant involvement of autonomic nervous system in particular organs and systems of the human body.

[Epidemiology of thyroid cancer in Poland]

The aim of the paper is to analyse the epidemiological situation of thyroid cancer in Cracow region from 1986 to 1999 and to review regional thyroid cancer registers in Poland (including 43.7% of the Polish population) in 1999. The standardized register was based upon assumptions: 100% of histopathological verification according to ICD-10, the register ascertainment in at least 80%, the demographic area not smaller than 100,000 inhabitants, the incidence rate (IR) calculated as the newly diagnosed cases number per 100,000 inhabitants in a calendar year. Since 1990 a statistically significant rise of the thyroid cancer incidence affecting mainly women > 40 years of age have been observed. From 1998-1999 the cancer morbidity was reduced. Within the last 5 years in the Cracow area the follicular carcinoma incidence has decreased significantly, which has been associated with effective iodine prophylaxis. The highest incidence values have been observed in Cracow and Olsztyn, showing a territorial relationship with the highest thyroid irradiation doses after Chernobyl accident. The mean IR value has been 3.86 (1.48 men, 6.08 women), which corresponds to about 1500 newly diagnosed cases in Poland in 1999. The follicular to papillary carcinoma ratio has been 5.32. The major etiological factors have been iodine deficiency and ionising radiation. The present data have indicated that iodine prophylaxis should be continued and that the population should be protected against ionising radiation.

[Iodine deficiency and thyroid neoplasms in the Krakow region]

The aim of the study was to evaluate the correlation between incidence rate (IR) of thyroid cancer and severity of iodine deficiency. The influence of iodine prophylaxis on IR was also investigated. The suspension of iodine prophylaxis in 1980 resulted in goitre prevalence increase in schoolchildren (up to 60%) and elevated TSH levels in neonates observed in early 1990-ties. In 1990 rise in thyroid cancer IR was observed. IR of papillary and follicular carcinoma in 1995 were 1.6 and 1.5 respectively. Papillary to follicular ratio was about 1.0. Such a high prevalence of follicular cancer was specific for iodine deficient regions. In 1997, after introduction of mandatory model of iodine prophylaxis in Poland, increase in papillary thyroid cancer IR was observed, reaching in 1998 6.23 per 100,000 inhabitants. Papillary to follicular cancer ratio rose to 2.48. In 1999 no further increase in thyroid cancer IR was observed. Increase in papillary cancer incidence between 1990 and 1999 may be related to overlapping of iodine deficiency and other cancer risk factors i.e. radiation after Chernobyl accident.

[Pituitary function after transsphenoidal surgery for pituitary adenoma]

Nowadays transsphenoidal surgery is the method of choice in most cases of pituitary adenoma treatment, both functioning and non-functioning. This method is considered to be safer than transcranial approach, as lower incidence of complications, particularly hypopituitarism, is observed. The aim of the study was to evaluate the pituitary function after transsphenoidal surgery. 20 patients (mean age 49.3 +/- 13.9 years) were included into the study. The anterior pituitary insufficiency was defined as an inadequate excretory response to metopirone, LH-RH and TRH stimulation. Diabetes insipidus was diagnosed based on clinical symptoms. Hypopituitarism was diagnosed after surgery in 7 patients, 3 cases had adrenal and gonadal insufficiency, 1 patient had insufficiency of the pituitary-thyroid and gonadal axis and 3 subjects panhypopituitarism. Diabetes insipidus was still present in 2 patients, 3 months after surgery. We conclude that transsphenoidal approach in pituitary adenoma surgery is connected with low risk of iatrogenic hypopituitarism.

[An oligosymptomatic case of pheochromocytoma]

A case of 34-year old female with incidentally diagnosed adrenal tumour is discussed. The patient complained only of mild headaches and heart palpitations and was not previously treated for hypertension. A diagnosis of pheochromocytoma was made. The diagnostic controversies arose because of subclinical course of the disease, slightly elevated biochemical markers of pheochromocytoma (catecholemines urinary excretion) and non-characteristic result of glucagon stimulation test results. The diagnosis was confirmed by histologic examination of tumour tissue. Presented case indicates the need for thorough clinical and hormonal evaluation of patients with incidentaloma (particularly, when adrenal tumour diameter is larger than 3 cm) to avoid serious complication of surgery treatment in case of misdiagnosis.

A programme of iodine supplementation using only iodised household salt is efficient--the case of Poland

BACKGROUND

Iodine prophylaxis in Poland started in 1935 and has been interrupted twice: by World War II and in 1980 for economic reasons. Epidemiological surveys carried out after the Chernobyl accident in 1989 as well as in 1992/1993 and in 1994 as a 'ThyroMobil' study, revealed increased prevalence of goitre in children and adults. Ninety per cent of Poland was classified as an area of moderate iodine deficiency, and 10%, in the seaside area, as mild iodine deficiency territory. Iodine prophylaxis based on iodisation of household salt was introduced again in 1986 as a voluntary model and in 1997 as a mandatory model with 30+/-10 mg KI/kg salt.

OBJECTIVE

The evaluation of the obligatory model of iodine prophylaxis in schoolchildren from the same schools in 1994 and 1999.

METHODS

Thyroid volume was determined by ultrasonography. Ioduria in casual morning urine samples was measured using Sandell-Kolthoff's method, within the framework of the ThyroMobil study.

RESULTS

Goitre prevalence decreased from 38.4 to 7% and urinary iodine concentration increased from 60.4 to 96.2 microg/l mean values between 1994 and 1999. In four schools the prevalence of goitre diminished below 5%. In 1999, 70% of children excreted over 60 microg I/l, and 36% over 100 microg I/l, whereas in 1994 the values were 44 and 13% respectively.

CONCLUSION

The present findings indicate that iodine prophylaxis based only on iodised household salt is highly effective.

[Neurological disturbances in the course of glucagonoma: a case report]

A case of 40-year-old patient with glucagonoma associated with neurological and consciousness disturbances is reported. The diagnosis of the tumour was based on clinical manifestations (diabetes mellitus, anaemia, weight loss, distant metastases), visualisation (USG, CT of the abdomen) and immunohistochemical staining of the biopsy of tumour metastatis to the liver. During the progress of disease paraplegia, other neurological symptoms and three episodes of coma were observed. This should be associated with the neurologic paraneoplastic syndrome and hepatic failure due to diffuse metastases to the liver, especially when no metastases to the central nervous system were found in CT. Although patient was treated with chemotherapy, disseminated neoplasmatic process was the cause of the fatal outcome.