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

BACKGROUND

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

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.

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.

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.

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.